Nokea
Which of the following are examples of medical battery? Select all that apply.
- A. A child is placed in a papoose restraint for suturing of a facial laceration with the parent present
- B. Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube
- C. The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline
- D. The nurse inserts a needed urinary catheter even though a competent client refuses it
- E. The nurse threatens to put a client in restraints if the client does not stay in bed
Correct Answer: C,D
Rationale: Administering morphine deceptively and inserting a catheter against a competent client's refusal constitute medical battery. Restraints and threats, while concerning, are not battery.
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At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her mind. The client's behavior most likely indicates
- A. Feelings of increasing anxiety related to paranoia
- B. Social isolation related to altered thought processes
- C. Sensory perceptual alteration related to withdrawal from environment
- D. Impaired verbal communication related to impaired judgment
Correct Answer: B
Rationale: Social isolation related to altered thought processes. Hostility and lack of engagement suggest isolation driven by paranoid thoughts.
Which of the following meals provides the lowest amount of potassium?
- A. Orange, cream of wheat, bacon
- B. Toast, jelly, soft boiled egg
- C. Raisin bran, milk, grapefruit
- D. Melon, pancakes, milk
Correct Answer: B
Rationale: Toast, jelly, and soft-boiled egg are low in potassium compared to fruits like oranges, grapefruit, or melon, which are high in potassium.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to
- A. verify correct placement of the tube
- B. check that the feeding solution matches the dietary order
- C. aspirate abdominal contents to determine the amount of last feeding remaining in stomach
- D. ensure that feeding solution is at room temperature
Correct Answer: A
Rationale: verify correct placement of the tube. Proper placement of the tube prevents aspiration.
A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse?
- A. 25-year-old client who reports a fish-like vaginal odor for the past month
- B. 30-year-old client with an intrauterine device who reports heavy bleeding with menses
- C. 40-year-old client with endometriosis who reports persistent pain during intercourse
- D. 60-year-old client who reports bloating and pelvic pressure for the past 2 months
Correct Answer: D
Rationale: Bloating and pelvic pressure in a 60-year-old client may indicate serious conditions such as ovarian cancer or other pelvic masses, which require urgent evaluation. Fish-like odor suggests bacterial vaginosis, heavy bleeding with an IUD is common, and pain with endometriosis is expected, making these less concerning.
A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication?
- A. Early decelerations
- B. Late accelerations
- C. Variable decelerations
- D. Periodic accelerations
Correct Answer: C
Rationale: When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.