Exam 2
"The process of bringing and trying this lawsuit is called litigation." "The opinions of appellate judges are published and become common law." "Common law is based on the principle of stare decisis." The process of bringing and trying a lawsuit is called litigation. The opinions of appellate judges are published and become common law. Common law is based on the principle of stare decisis, or "let the decision stand." After a decision has been made in a court of law, the principle in that decision becomes the rule to follow in other similar cases (precedent). The other options listed are not true about the litigation process.
A lawyer is describing the litigation process to a nurse named in a malpractice lawsuit. Which statements by the lawyer accurately describe this process?
state nurse practice act (NPA) Each state has its own NPA, which determines what the nurse is allowed to do in each particular state, providing constraints within which nurses practice. The NPA delineates scope of practice. Therefore, the manager would contact the NPA in this scenario. The other sources are not appropriate given the context of the scenario.
A medical-surgical unit manager intends to have licensed practical nurses (LPNs) in the unit administer intravenous push (IVP) medications. What source would the manager contact to include this procedure in the LPNs' practice?
"Will this case be precedent setting?" Most law involving malpractice is common law. If a case is the first to set down a rule by its decision, a precedent will be set. Statutory law, such as state nurse practice acts, is enacted by the legislature. The findings of the case are binding in a common law case. The law establishing a board of health is known as administrative law.
A nurse has been named in a malpractice lawsuit. Prior to taking the nurse's deposition, the attorney explains that the case will be governed by common law. Which question by the nurse is indicated?
Newborns and children using abdominal muscles during respiration Older adults having an increased anterior-posterior (AP) chest diameter Older adults having an increase in the dorsal spinal curve (kyphosis) Newborns and children use abdominal muscles to breathe as opposed to adults, who use the thoracic muscles. Increased anteroposterior diameter of the chest is seen in older adults. Kyphosis is seen in older adults. Newborns and children have louder breath sounds and a higher respiratory rate than adults. Older adults have decreased thoracic expansion.
A nurse is assessing several clients with respiratory problems. Which findings would the nurse document as normal, age-related thorax and lung variations?
a reddish retina Normal findings of the internal eye structures include a uniform red reflex; round white or pink optic nerve disc; reddish retina; and bright-red arterioles and dark-red veins.
A nurse is assisting with assessment of the internal eye structures of clients in an ophthalmologist's office. What would the nurse document as a normal finding?
the client makes noises when he breathes Noisy respirations are a sign of a narrowed airway that could be caused by postoperative bleeding or edema. This finding requires an immediate intervention. Reports of thirst after being NPO for at least 8 hours before surgery and pain at the surgical site are expected findings. Feeling sleepy from the anesthesia is an expected outcome.
A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse?
battery Battery is intentional and wrongful physical contact with a person that entails an injury or offensive touching. Performing treatment without permission or receiving informed consent from the client might constitute both assault and battery. Judgments of battery suits have been based on the application of restraints to confused clients. Slander is a verbal attack on a person's character. Malpractice pertains to actions committed and negligence to actions omitted that cause physical harm to a client.
A client admitted to a mental health unit has exhibited physical behaviors that put the client and others at risk. The nurse applies four-point restraints on the client without obtaining a physician's order or the client's consent. The nurse is at risk of being accused of which action?
bed scale A bed scale is used for clients who are too weak or immobile to use other scales safely.
A client had a cerebrovascular accident yesterday and is currently comatose. What type of scale should the nurse use to weigh the client?
Arrange a meeting where the issue can be discussed and addressed by as many of the nurses as possible Open, explicit, and participatory conflict resolution that is based on collaboration is an effective strategy for the management of conflict. Gathering evidence does not directly address the conflict that currently exists and reassurance may be unwarranted and false. Allowing the new graduates to create the client assignment may perpetuate selfish practices and does not resolve animosity between the two camps.
Conflict has emerged on a nursing unit due to the perception by new graduates that some of the more experienced nurses are manipulating the client assignment to ensure a lighter workload during night shifts. How should the manager of the unit best address this conflict?
A nurse threatens to hit an older client who has dementia and is screaming. A nurse seeks employment in a hospital after falsifying credentials on a resume. A nurse places a client who is a fall risk in restraints without an order from the health care provider. A nurse makes disparaging remarks to the staff about a client who has a sexually transmitted infection (STI). Torts may be intentional or unintentional acts of wrongdoing. Some of the intentional torts for which nurses may be held liable include assault and battery. Examples of intentional torts would include a nurse threatening to hit an older client who has dementia and who is wailing; a nurse seeking employment in a hospital after falsifying credentials on a resume; a nurse placing a client who is a fall risk in restraints without the proper order; a nurse making disparaging remarks to the staff about a client who has a sexually transmitted infection. A nurse forgetting to put the side rail up on a crib would be an example of an unintentional tort, as would a nurse not reporting a change in client condition in a timely manner.
Nurses may commit both intentional and unintentional torts when practicing within the profession. What intentional torts may occur in nursing practice?
Client-centered care Teamwork and collaboration Evidence-based practice Quality improvement The QSEN has identified client-centered care, teamwork and collaboration, evidence-based practice, and quality improvement as a means for nurses to improve the quality and safety of client care wherever they work. Additional key competencies identified are safety and informatics. Correct documentation is not a QSEN competency.
The Quality and Safety Education for Nurses (QSEN) initiative has identified which key competencies for nurses?
Patient-centered care Teamwork and collaboration Evidence-based practice Quality improvement QSEN has identified quality and safety competency categories for education. In prelicensure nursing programs, students learn using the quality and safety competency categories of patient-centered care, teamwork and collaboration, evidence-based practice, and quality improvement. Nursing process and therapeutic communication were not identified as quality and safety competency categories.
The Quality and Safety Education for Nurses (QSEN) project has developed quality and safety competency categories. What are the quality and safety competency categories that students are encouraged to develop during prelicensure education?
Breach of duty has occurred The nurses had a duty to care for the client and breached duty by not assessing the client in 7 hours. No determination of the nurse or facility's response is made until a complete investigation is done.
The evening nurse received a change-of-shift report from the day nurse. The day nurse's report states, "The client required intubation for respiratory distress this morning, but has been stable all day." The evening nurse collects the following information during the first assessment: Skin flushed. Client lethargic. Temperature 103.0°F (39.4°C). A review of the client's chart reveals that the client's last assessment was done 7 hours earlier. A review of the findings by the nurse attorney determines which facts might be in place regarding liability?
Decreased near vision Increased systolic and diastolic blood pressure Decreased tissue elasticity Presbyopia (decreased vision), and the others are normal signs of again. Others are not.
The nurse entered the room of an older adult client diagnosed with Alzheimer's disease to perform a head to toe assessment. What assignment findings by the nurse are reflective if normal signs of aging?
"I am going to insert a catheter in you if you do not get up to go to the bathroom." "Hold still for these stitches otherwise I am going to have to hold you down." Assault is a threat or attempt to make bodily contact with a person without the person's consent. Threatening an intervention, such as a urinary catheter or restraint, when the client has not consented to it is assault. Taking an object out of a client's hand without consent is battery. Holding a client's hand or helping a client remove clothing is not assault or battery unless the client has asked the nurse not to do so.
The nurse is assigned to various clients on a medical unit. Which statements made to clients by the nurse constitute assault?
Assault Defamation of character Negligence Torts are intentional or unintentional acts of wrongdoing. Some of the intentional torts for which nurses may be held liable include assault and battery, defamation of character, negligence, invasion of privacy, false imprisonment, and fraud. Manslaughter and robbery are crimes.
Which are torts rather than crimes?
Percussion This is the act if striking one objected against another to produce sound. The fingertips are used to tab the body over body tissue to produce vibrations and sound waves. The location, shape, size, and density of the organ or tumor are added with this method. The characteristics that can determine about a tumor by palpate include, shape, size, consistency, surface, mobility, tenderness, pulsatile.
Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?
The LPN/LVN should work under the supervision of an RN LPNs/LVNs are employed in hospitals, long-term care facilities, and rehabilitation centers and by health care providers such as physicians. LPNs/LVNs differ from RNs in two areas: educational preparation and scope of practice. LPNs always practice under the supervision of an RN. LPNs have a scope of practice and the workload is not directed by the RN. RNs are not permitted to prescribe medications. Nurse practitioners may prescribe medications.
Which explanation accurately differentiates the role of the registered nurse (RN) from that of the licensed practical/vocational nurse (LPN/LVN)?
American Nurses Association (ANA) The ANA produced the 2015 Nursing: Scope and Standards of Practice, which defines the activities specific and unique to nursing. The AACN addresses educational standards, while the NLN promotes and fosters various aspects of nursing. The ICN provides a venue for national nursing organizations to collaborate, but does not define standards and scope of practice.
Which organization is the best source of information when a nurse wishes to determine whether an action is within the scope of nursing practice?
A nurse who demonstrates advanced expertise in a content area of nursing through special testing Certification is a voluntary process whereby a person who has met criteria established by a nongovernmental association is granted special recognition in a specified practice area. Licensure is granted by the state to a graduate of a nursing education program who passes NCLEX-RN. Accreditation is a voluntary process by which a nursing education program is recognized as having met certain standards by the NLN Commission for Nursing Education Accreditation and/or the American Association of Colleges of Nursing. The Joint Commission can also accredit health care agencies.
Which scenario is an example of certification?
let me tell you what I will be doing. it should not be painful. Tell the client the assessment should not be painful and explain the assessment in general terms that can help the client embarrassment, fear of possible abnormal physical findings, or fear of failing the test.
a nurse is preparing for physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate.
sense of vision, hearing, and smell inspection is the process of performing deliberated, purposeful observations. The nurse observes visually but uses hearing and smell to gather data throughout the assessment.
a nurse is using inspection as an assessment technique. what does the nurse use during inspection?
Snellen chart This is used as a screening test for distant vision. it consist of characters n 11 lines of different size type, the with largest character at the top and the smallest at the bottom. Vision is recorded as score.
a nurse working in the clinic is planning to conduct a vision screening for adults. What equipment would be needed to test vision?
ask the client to follow her finger as she slowly moes it toward the client's nose eye convergence is assessed by holding your finger 6 to 8 inches from the clients nose and asking the client to follow it as it moves closer. Following pencil from side to side is a test for extraocular movements.
as a component of the head to toe assessment, the nurse is preparing to assess convergence of the clients eyes. how should the nurse conduct this assessment?
frequency Frequency and character are listened to when assessing bowel sounds.
the client reports experiencing abdominal pain. the nurse auscultates the client abdomen and hears gurgling sound. what additional information does the nurse assess about the gurgling sound?
decreased cardiac output a weak, thready pulse may indicate a decreased cardiac output
the nurse detects a weak, thready pulse found from a client palpating peripheral pulses. What condition does the nurse suspect the client is experiencing?
decreased heart rate Infant and children should have a more rapid heart rate, until age 8. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increased with inspiration and decreases with expiration) and the presence of an S heart sound
the nurse is performing as assessment on an infant. Which findings is considered an abnormal cardiovascular assessment that should be documented and reported to the primary care provider?
focused a focused assessment is conducted to assess a specific problem. in this case, the nurse would ask the client about urinary frequency, bowel movement, and diet, and then take vital signs and assess the abdomen.
a home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have has a lot of pain in my abdomen." What type of assessment would the nurse conduct?
the institutional ethics committee. Many healthcare institutions have developed ethics committees, whose functions include education, policy-making, case review, and consultation. These committees are multidisciplinary and provide a forum where divergent views can be discussed without fear of repercussion. Thus, an institutional ethics committee would be an appropriate entity for addressing this ethical dilemma. A client's family would not likely be able to determine whether routine laboratory testing was necessary and therefore ethical and, in any case, would not be objective. The physician and charge nurse would not be objective, either, as they might be implicated in establishing or maintaining this practice. However, the physician and charge nurse could be helpful to the ethics committee by explaining why these tests are necessary and the current and projected care of the client.
A nurse is concerned about the practice of routinely ordering an extensive series of laboratory tests for clients who are admitted to the hospital from a long-term care facility. An appropriate entity for addressing this ethical dilemma would be:
Ability to open and close eyelids Pupillary reaction to light Cranial nerve ||| is an oculi Igor is involved pupil construction and raiding the eyelids.
A nurse is examining a client and is testing the client cranial neveres, which action would the nurse use to evaluate cranial nerve |||?
Decreased color vision and peripheral vision Entropion and ectropion Impaired conductive hearing Decreased adaptations of light and dark. White ring around the cornea (arcus senilis) entropion is a condition where the Elric is rolled inward against the eyeball, caused by muscle spasms or inflammation or scaring of the conjunctiva. Ectropion is when the lower eyelid turns or sags outward, away from the eyes, exposing surface of the inner eyelid. Causes dryness, tearing, irritation.
A nurse is performing physical assessment of residents in a long term care facility. What common head and neck variations in the older adults does the nurse document as normal finding?
the nurse provides emotional and physical preparation to the client The nurse is responsible for preparing the client emotionally and physically for diagnostic procedures and tests, such as the barium enema. Other responsibilities include witnessing the client's consent, scheduling the test, providing care during the procedure or test, and disposing of used equipment. The nurse does not write the order, delegate care to others, or record test results.
A nurse is preparing a client for a barium enema. What activity would the nurse include in preparing the client for the barium enema?
Reflexes This is the initial assessment after a spinal cord injury. There for it would be top priority. Motor ability and gait can be assessed after because further injury could result. Sensory ability are added through smell taste heating and vision
A nurse is testing the function of the spinal cord of a client who presents in emergency department following a motorcycle accident. What would be the focus of the assessment?
Penlight A penlight is used to test pupillary response to light and accommodation. None of the other items listed would be needed for this assessment.
A nurse needs to test a client's pupillary response to light and accommodation. Which item will the nurse need for this assessment?
filling out an incident report accurately after a client went missing from the unit Filling out an incident report correctly is an example of a skill that aligns with the QSEN competency of safety. According to the ANA, there are six focus-area competencies in QSEN: 1) patient-centered care, 2) evidence-based practice, 3) teamwork and collaboration, 4) safety, 5) quality improvement, and 6) informatics. "Valuing" and "appreciating" are indications of a nurse's attitude, not skills. "Understanding" is an indication of knowledge.
A nurse on a medical unit recognizes the need to demonstrate Quality and Safety Education for Nurses (QSEN) competencies in clinical practice. Which action best demonstrates the skills necessary to meet the QSEN competency of safety?
A nurse reads The Patient Care Partnership to a visually impaired client. A nurse asks the surgeon to further explain details of a surgery to a client before obtaining informed consent. The professional value of autonomy is the right to self-determination. When the nurse reads The Patient Care Partnership to a visually impaired client, the nurse is demonstrating autonomy. A nurse asking the surgeon to further explain details of a surgery to a client before obtaining informed consent is another example of autonomy. Staying past the end of a shift and researching a new procedure demonstrate the ethical principle of beneficence. Keeping a promise to call a client's healthcare provider demonstrates the ethical principle of fidelity. Seeking the help of a more experienced nurse to insert a catheter in a client demonstrates the ethical principle of nonmaleficence.
A nurse practices the ethical principle of autonomy when providing nursing care for clients. Which nursing actions best describe the use of this value?
Libel HIPAA Slander Slander is the spoken defamation of character; libel is written defamation. HIPAA rules are violated when a client's personal information is disclosed. The use of the client's room number and name make her presence in the facility discoverable. The nurse did not threaten the client (assault) or physically touch the client (battery).
A nurse suspects that a client is a prostitute. The nurse documents this suspicion in the medical record and includes it in report to the oncoming shift. The nurse also mentions the suspicion to the nurse's sister saying, "I had a client named Susan in room 126 today who I think is a prostitute." Which violations has this nurse committed?
20/20 or 6/6 Normal vision is at or near 20/20 or 6/6, full field of vision, and tricolor vision (red, green, blue).
A parent of a school-age child is told that her child has normal vision. The school nurse explains that the child's vision is:
licensed or vocational nursing program A licensed practical or vocational nursing program will allow the student to earn a technical certificate in 1 year and sit for the state board of nursing examination to be licensed as an LPN or LVN. This would allow employment that will allow the graduate to provide client care and to assist professional nurses with routine technical procedures as desired. An associate program will take 2 years and a baccalaureate program will take 4 years; additionally these prepare new nurses to work in a more independent role than this person is seeking. There are very few diploma programs remaining in the U.S., and these programs typically take 3 years to complete.
A prospective nursing student desires a career that will allow the opportunity to provide client care and to assist professional nurses with routine technical procedures. The prospective student needs to be employed in a full-time position quickly due to economic hardship. What type of nursing program would best suit this student?
It is the purpose of assistive personnel to work in a supportive role to the registered nurse. It is the role of the assistive personnel to carry out tasks to enable the professional nurse to concentrate on nursing care for the client. It is the registered nurse who is responsible and accountable for nursing practice The nurse must be familiar with the delegation guidelines when working as a registered nurse. The purpose of assistive personnel is to work in a supportive role to the registered nurse. It is the role of the assistive personnel to carry out tasks to enable the professional nurse to concentrate on nursing care for the client. It is the registered nurse who is responsible and accountable for nursing practice. It is the nursing practice act of each state, not the health care institution, that determines the scope of nursing practice within a given state. The LPN does not supervise the assistant, the RN does. It is not the role of the LPN, rather the RN, to assign nursing duties.
A registered nurse checks the American Nurses Association (ANA) regulations prior to delegating tasks to unlicensed assistive personnel (UAP) on a burn unit. Which principles regarding the regulation, education, and use of UAP are recommended by the ANA?
State board of nursing State boards of nursing are enacted to ensure that schools preparing nurses maintain minimum standards of nursing education. This is legal accreditation. Accreditation by voluntary agencies such as NLN, AACN, and ANA are not required for a nursing school to exist.
Accreditation by which organization is legally required for a school of nursing to exist?
Asking the LPN/LVN to teach a new diabetic client how to administer insulin Negligence is harm that results because a person did not act reasonably. As nurses perform the role of delegators, they must know which tasks are legal and appropriate for particular health care providers to perform (scope of practice), as well as the policy for the facility at which they are employed. Teaching is not in the current scope of practice for a LPN/LVN, and thus the RN's delegation of this task to the LPN/LVN could be considered negligence. The other actions are within the scope of practice for a LPN/LVN.
An RN is working on a medical-surgical unit with a licensed practical/vocational nurse (LPN/LVN). Which action by the RN is considered negligent if injury results from this action?
To assess capillary refill and oxygenation Palpation of the nails is done to assess capillary refill and oxygenation. The other answers pertain to assessment of the skin.
During a head-to-toe assessment of a client, the nurse carefully palpates the client's nails. Which is the best rationale for this technique?
Being trusted to act in ways that advance the interests of clients Being accountable for practice to oneself, the client, the caregiving team, and society Acting as an effective client advocate Skills necessary in being proficient in legal/ethical competencies include being self-motivated to act in ways that advance the interests of clients (consistently trustworthy); being accountable for practice to self, clients served, the caregiving team, and society; consistently serving as an effective client advocate; being skilled in mediating ethical conflict among the client, significant others, health care team, and other interested parties; practicing nursing that is faithful to the tenets of professional codes of ethics; and using legal safeguards that reduce the risk of litigation. Being respected and viewed as credible meets competency needs of the interpersonal skills competency. Using technical equipment with competence to meet the needs of the client is an example of proficiency in the technical competency category. Selecting interventions that yield desired outcomes demonstrates cognitive competency.
Nurses who embrace their role in securing client well-being are sensitive to the ethical and legal implications of nursing practice. Which attributes are examples of these ethical/legal skills?
American Nurses Credentialing Center (ANCC) Nurses can choose to become certified in a nursing specialty. The American Nurses Credentialing Center (ANCC, 2014) states that certification validates nursing specialty knowledge. Also, it builds confidence in nurses as professionals, demonstrating that they meet nationally recognized standards in the specialty. Certification is a voluntary process to provide professional recognition of the knowledge, skills, and abilities of certified nurses. The American Nurses Association is a professional organization to advance and protect the profession of nursing. It started in 1896 as the Nurses Associated Alumnae and was renamed the American Nurses Association in 1911. The National League for Nursing is a national organization for faculty nurses and leaders in nurse education. The American Association of Colleges of Nursing (AACN) is the national voice for baccalaureate and graduate nursing education.
The nurse is considering medical-surgical certification after working in a medical-surgical floor for the past five years. Nursing specialty certification is given by which group?
Client advocate Nurses act as client advocates in many situations. Examples include communicating the needs and concerns of clients and ensuring that clients understand their treatments. In this case, the nurse is advocating for the client by providing the client dignity of personal hygiene and cleanliness. The nurse is not teaching as in the role of the educator. The nurse is not deciding on what is best for the client as a decision maker. The nurse is not managing the client nor coordinating care with other health care providers.
The nurse is helping the unlicensed assistive personnel (UAP) bathe the client, who is experiencing a lot of pain when repositioned in bed. Which nursing responsibility is the nurse demonstrating?
"Do you have a difficult time administering your own medications?" "Do you require assistance with bathing or dressing?" "How do you meet your transportation needs?" Performing a functional assessment includes asking about the physical limitations or abilities that a client may experience such as how the client is able to manage transportation, bathing, medication administration, and dressing. Coping with stressors would be included in the psychosocial/lifestyle assessment as well as the use of alcohol, tobacco, and illicit drugs.
The nurse is performing an assessment of a client's functional health. What questions asked by the nurse would obtain useful information for this assessment?
Position the client supine and drape appropriately Inspect the skin of the thorax and abdomen Palpate the thorax Auscultate the thorax Auscultate the abdomen Palpate the abdomen Wash hands. Provide privacy for client. Supine. Inspect first. Palpate. Auscultate. Exception of the abdomen
The nurse is preparing to assess the thorax and abdomen of a Cline rising the head to toe physical assessment method. Place the assessment techniques in order in which they should be performed.
Radial Brachial Popliteal Posterior tibial Dorsalis pedis These are all located in extremities. Femoral artery is in the groin region.
The nurse is preparing to palpate a clients peripheral pulses. The nurse should plan to assess which pulses?
|||. oculi motor |V. Trochlear VI. Abducens These control motor function of the eye structures, which can be assessed through movement of the eyes through 6 cardinal positions of gaze. Optic nerves controls the sense of vision (sensory).
The nurse testing a clients eyes ask the client to to focus on a finger from 60cm away and moved the clients eyes through the 6 cardinal positions of gaze. Using this procedure, which cranial nerves is this nurse testing?
the nurse is able to identify actual and potential health problems of the client The nurse uses the nursing process when providing care to clients. The nurse organizes and documents assessment data to identify actual and potential health problems, makes nursing diagnoses, plans appropriate care, and evaluates the client's response to treatment. The purpose of assessments is to identify actual and potential problems of the clients. It is not to identify the nurse's role in health care, nor is it to expand nursing knowledge and skills. By identifying client problems, nurses are able to use evidence-based nursing care when intervening.
The nurse, after receiving a report on assigned clients, begins assessments of the clients. What is the primary purpose of assessing clients?
The nurses agree for one nurse to obtain the preceptor for orientation in exchange for that nurse working each weekend Accommodation involves one party deciding to let the other party win in exchange for something else of value, such as one nurse agreeing to let the other have the preceptor in exchange for the first nurse not having to work weekends. Each nurse ignoring the other's request illustrates avoidance. Allowing the preceptor to decide which nurse to precept encourages competition. Competition involves a win-lose approach to conflict. Collaborating is a joint effort to resolve the conflict with a win-win solution in which all parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal.
Two new nurses are requesting the same preceptor for unit orientation and say they will be unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using an accommodating approach to conflict resolution?
Accommodating The nurse manager is displaying a conflict resolution style of accommodating by asking one of the nurses to accept the assignment of the admission. If the nurse manager had ignored the situation, this would have been the avoiding style of conflict resolution. With a competing style, the nurse manager would have told the nurse to accept the admission, rather than asking the nurse. If collaborating is the conflict resolution style used, the nurse manager would have discussed the situation with both nurses in order to achieve a solution to this conflict.
Two nurses are having a disagreement over who will take the next admission to the unit. The nurse manager asks one of the nurses to take the admission and explains that this will be considered a personal favor. Which style of conflict resolution did the nurse manager display?
inspection Inspection is the process of performing deliberate, purposeful observations in a systematic manner. The nurse closely observes a specific area visually, as using the senses of hearing and smell to gather data throughout the assessment. The color, shape, and contour of the client's chest would be assessed with this method. Neither palpation nor auscultation would not provide the color of the chest; percussion would not provide the color, shape, or contour of the chest.
What assessment technique would the nurse use to assess a client's chest for color, shape, or contour?
The nurse told the client, "The doctor prescribed this medication, and you must take it. I'll force you to take it." The nurse tells another employee, "Everyone knows the previous nurse does not do the job and charts medications not administered." The nurse administered a sedative medication to a sleeping client because the client's child requested the parent receive it. Examples of nurses committing a tort are the nurse telling the client, "I'll force you to take it" (assault), the nurse telling another employee that the previous nurse "charts medications not administered" (slander), and the nurse administering a sedative medication to a sleeping client without the client's permission (false imprisonment). Medications can be a restraint. The nurse applying a vest restraint and the nurse forcibly restraining the client threatening self-harm are acceptable actions in those situations.
Which scenarios are examples of a nurse committing a tort?
The nurse maintains standards of personal conduct. The nurse is active in developing a core of research-based principles. The nurse holds personal information as confidential. The ANA Code of Ethics states: "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." Standards of personal conduct, developing research, and confidentiality are all tenets of the Code of Ethics for Nurses. Fair compensation and participation in the advancement of the profession are related to the Bill of Rights for Registered Nurses, not the Code of Ethics for Nurses.
Which statements indicate a correct understanding of the tenets of the Code of Ethics for Nurses?
Assault The staff member's statement reflects a threat of contact with another person without the person's consent. This is considered assault. Battery is an assault that is carried out and includes willful, angry, and violent or negligent touching of another's body or clothes (or anything attached to or held by that person). False imprisonment is the unjustified retention or prevention of the movement of another person without proper consent. This would apply if the staff member did in fact tie the client to the chair. Invasion of privacy involves the disclosure of information without the person's consent.
While walking down the hall, a nurse manager overhears a staff member telling a client, "If you don't stay in this chair and stop wandering, I'm going to tie you to it." The nurse manager pulls the staff member aside and discusses what was said. The nurse manager intervenes because the staff member's statement is which type of tort?
stridor indicated narrowing of the upper airway (larynx or trachea) caused y the obstruction or edema and must receive priority of care. Expiratory wheezing is caused by air passing through the narrowed lower airways.
a 7 year old child is admitted to the emergency department with a tentative diagnosis of asthma. Which assessment required a priority intervention by the nurse?
crackles describes are bubbling or popping sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. Sibilant wheezes are high pitched and shill-sounding breath sounds that occur when the airway becomes narrowed. They often have musical quality to them. These are typical wheezes heard when listening to an asthmatic patient. A sonorous wheeze is an added sound with musical pitch occuring during inspiration or expiration, heard on auscultation of the chest and caused by air passing through bronchi that are narrowed by inflammation, spasms of smooth muscle, or presence of mucus in the lumen. A friction rub is a continuous, grated-type sound.
the nurse is providing care for male client age 69 years who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung field. what should the during document as being present?
temperature, tugar, moisture application is using the sense of touch. Hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and the shape.
what of the following can a nurse assess by palpation?