Nokea
Which of the following statement is TRUE about assault?
- A. Touching the client without consent
- B. An intentional threat
- C. Causes physical harm
- D. All of the above
Correct Answer: B
Rationale: Assault is an intentional threat (B), per law e.g., menacing gesture, no contact needed. Touching (A) is battery, harm (C) not required, all (D) oversteps. B truly defines assault's intent, making it correct.
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Which of the following urine color is considered normal?
- A. Dark amber
- B. Yellow, Cloudy
- C. Light Yellow, Amber
- D. Slightly pale yellow
Correct Answer: D
Rationale: Slightly pale yellow is normal e.g., hydrated urine per standards. Dark amber (dehydration), yellow cloudy (infection), light yellow amber (concentrated) differ. Nurses assess e.g., hydration for health, per norms.
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
- A. Instructing the patient about this diagnostic test
- B. Writing the order for this test
- C. Giving the patient breakfast
- D. All of the above
Correct Answer: C
Rationale: The nurse ensures the patient eats, while the physician handles test orders and instructions.
You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:
- A. did the right thing because the client improved.
- B. should have had the family put their request in writing.
- C. have commited an assault against the client.
- D. have committed an act of battery against the client.
Correct Answer: D
Rationale: Administering a vitamin B injection to a competent client who refuses it, despite family insistence and subsequent improvement, constitutes battery. Battery is the unlawful physical contact with a person without consent, and in healthcare, consent is a fundamental right for competent adults. The client's objection overrides family wishes, and giving the injection violates autonomy, a core ethical principle. The outcome of improvement doesn't justify the action legally or ethically. Assault involves threatening harm, whereas battery is the act itself, making this the correct classification. Getting family requests in writing or focusing on the outcome doesn't negate the lack of consent. This scenario underscores the importance of respecting patient rights and the legal consequences of disregarding them, even with good intentions.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.
Which technique would be best in caring for a client following receiving a diagnosis of a stage IV tumor in the brain?
- A. Offering the client pamphlets on support groups for brain cancer
- B. Asking the client if there is anything he or his family needs
- C. Reminding the client that advances in technology are occurring everyday
- D. Providing accurate information about the disease and treatment options
Correct Answer: D
Rationale: Accurate information empowers the client and family to make informed decisions.