Practice questions
The nurse is performing and documenting the findings of an abdominal assessment. When the nurse hears intestinal rumbling and the patient then experiences diarrhea, the nurse documents the presence of which of the following? a) Diverticulitis b) Borborygmus c) Azotorrhea d) Tenesmus
Borborygmus Explanation: Borborygmus is the intestinal rumbling that accompanies diarrhea. Tenesmus is the term used to refer to ineffectual straining at stool. Azotorrhea is the term used to refer to excess of nitrogenous matter in the feces or urine. Diverticulitis refers to inflammation of a diverticulum from obstruction (by fecal matter) resulting in abscess formation.
The nursing student talks with the student's family about an AIDS client from the clinical experience. Which tort has the student committed? a) Invasion of privacy b) Assault c) Fraud d) Slander
Invasion of privacy Explanation: Invasion of privacy involves a breach of keeping client information confidential. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Slander is oral defamation of character. Assault is a threat or attempt to make bodily contact with another person without that person?s consent.
Nurse Practice Acts are examples of which type of laws? a) Administrative law b) Constitutional laws c) Statutory laws d) Common law
Statutory laws Explanation: Nurse Practice Acts are statutory laws. Statutory laws must be in keeping with both the federal constitution and the state constitution.
A nurse overhears another nurse say to a client, "If you do not stop spitting, I'm going to leave you outside in your wheelchair so that you miss your dinner." What is the most appropriate response by the nurse who overhears this conversation? a) "Your verbal threats to the client are legally considered assault." b) "I think you need to review therapeutic communication techniques." c) "Could you clarify for me whether you were joking with the client?" d) "I will have to report you for unprofessional behavior toward a client."
Your verbal threats to the client are legally considered assault." Explanation: Assault is conduct that makes a person fearful and produces a reasonable apprehension of harm. The nurse's behavior in legal terms is assault.
The nurse is conducting an educational program on the Health Insurance Portability and Accountability Act (HIPAA) of 1996 for unlicensed personnel. The nurse determines that the unlicensed personnel understand HIPAA when they state that it prohibits which of the following? a) Insurance coverage exclusions: coverage based on specific conditions b) Use of genetic information to establish insurance eligibility c) Two physicians from discussing their patient's condition d) Interdisciplinary team care-planning sessions
Use of genetic information to establish insurance eligibility Explanation: The Health Insurance Portability and Accountability Act (HIPAA) of 1996 prohibits the use of genetic information to establish insurance eligibility. It does not prohibit physicians involved in a patient's care from discussing the patient's condition, interdisciplinary team care-planning sessions, or insurance coverage exclusions based on specific conditions.
A client with severe acute respiratory syndrome privately informs a nurse that he does not want to be placed on a ventilator if his condition worsens. The client's wife and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to: a) encourage the client to consider a living will or power of attorney. b) ask the physician to discuss the client's prognosis with the client and and the family. c) arrange a conference to discuss the matter with all involved. d) assure the client that all possible measures will be taken.
encourage the client to consider a living will or power of attorney. Explanation: The nurse is obligated to act as the client's advocate. A living will or power of attorney would clearly define the client's wishes. The nurse should not discuss the issue with the client's family unless the client gives permission. Assuring the family and client that all possible measures will be taken opposes the client's wishes and does not demonstrate client advocacy.
A client that works as a pilot tells the nurse that he uses illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide her interaction with the client, which is the nurse's best response? a) "Using drugs jeopardizes your health and you should consider quitting." b) "You could easily have an error in judgement and cause a serious accident." c) "There's a problem with you choosing to use drugs as a way to cope with the stressors you experience." d) "If tested, you will lose your job."
"You could easily have an error in judgement and cause a serious accident." Explanation: Because her statement refers to those who could be harmed as a result of the pilot's drug use, the nurse's suggestion that the client should consider how an error in judgment could result in a serious accident reflects the principle of nonmaleficence (the obligation to do no harm). Telling the client that recreational drug use jeopardizes his health and decision-making ability addresses the personal danger of drug use, not the principle of nonmaleficence. Commenting that the pilot could test positive in a random drug test does not address any of the four basic ethical principles (autonomy, beneficence, nonmaleficence, and justice). Telling the client that there is a problem with his use of drugs to cope with stress reflects the principle of autonomy by addressing how his actions influence the rights of others.
Choice Multiple question - Select all answer choices that apply. A nurse is explaining the preparation of a death certificate to a student nurse. Which statements accurately describe this process? (Select all that apply.) a) A physician's signature is required on a death certificate. b) It is the nurse's responsibility to ensure that the physician has signed a death certificate. c) The nurse assumes responsibility for handling and filing the death certificate with the proper authorities. d) U.S. law requires that a death certificate be prepared for each person who dies. e) A death certificate is signed by the pathologist, the coroner, and others in special cases. f) Death certificates are sent to a national health department, which compiles many statistics from the information.
• U.S. law requires that a death certificate be prepared for each person who dies. • A physician's signature is required on a death certificate. • It is the nurse's responsibility to ensure that the physician has signed a death certificate. • A death certificate is signed by the pathologist, the coroner, and others in special cases. Explanation: Death certificates are required in all deaths in the U.S., must be signed by a physician, and the pathologist or coroner. The nurse must ensure that death certificates are signed. Death certificates are sent to local health departments. The mortician handles and files death certificates.
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? a) Maintaining the client without liquids before the procedure b) Having the client sign a consent form for the procedure c) Explaining to the client that the procedure will be painful d) Inserting a Foley catheter the morning of the procedure
Having the client sign a consent form for the procedure Explanation: The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.
A patient who was brought to the emergency room for gunshot wounds dies in intensive care 15 hours later. Which statement concerning the need for an autopsy would apply to this patient? a) An autopsy should not be performed because the nature of death has been established. b) The closest surviving family member should be consulted to determine whether an autopsy should be performed. c) The physician should be present to prepare the patient for an autopsy. d) The coroner must be notified to determine the need for an autopsy.
The coroner must be notified to determine the need for an autopsy. Explanation: If death is caused by accident, suicide, homicide, or illegal therapeutic practice, the coroner must be notified, according to law. The coroner may decide that an autopsy is advisable, and does not need the permission of the family for the autopsy to be performed. The physician does not need to be present during the autopsy, only the designated person performing the autopsy (medical examiner or pathologist).
A physician is called to see a client with angina. During the visit the physician advises the nurse to decrease the atenolol to 12.5 mg. However, since the physician is late for another visit, she requests that the nurse write down the order for her. What should be the appropriate nursing action in this situation? a) The nurse should write the order and implement it. b) The nurse should inform the client of the change in medication. c) The nurse should remind the physician later to write the work order. d) The nurse should ask the physician to come back and write the order.
The nurse should ask the physician to come back and write the order. Explanation: The nurse should ask the physician to come back later and write down the order. However, nurses are discouraged from following any verbal orders, except in emergency. The nurse should never write an order on a physician's behalf because this is a wrong practice. The client should be informed about the change of medications, but this is not an appropriate action. The nurse should not leave the work for a later time, because the nurse may forget it.
The cardiac nurse, who has been caring for a hospitalized terminally ill client for 3 days, finds that the client has expired. The nurse manager knows that the nurse can legally care for these clients when the nurse states which of the following? a) "I need to notify the coroner of all deaths." b) "The physician will give consent for the autopsy." c) "Hospitals are mandated to notify transplant programs of potential donors." d) "Organs are only retrieved from totally brain-dead clients."
"Hospitals are mandated to notify transplant programs of potential donors." Explanation: The scarcity of organs has resulted in legislation mandating hospitals to notify transplantation programs of potential donors. Consent for autopsy is legally required, usually from the closest surviving family member. It is usually the physician's responsibility to obtain permission for an autopsy. If death is caused by accident, suicide, homicide, or illegal therapeutic practice or if it occurs within 24 hours of admission to the hospital, the coroner must be notified. Organs can be obtained from brain-dead clients and non-heart-beating cadavers.
A staff nurse is caring for a client who is a potential heart donor. The client's family is concerned that the recipient will have access to personal donor information. Which response by the nurse demonstrates knowledge of the organ donation process? a) "There is never contact between the donor's family and the recipient." b) "I will have the transplant coordinator speak with you to answer your questions." c) "The recipient is allowed to ask questions about the donor and have them answered." d) "It is important that the recipient know where to send Thank-You cards."
"I will have the transplant coordinator speak with you to answer your questions." Explanation: The transplant coordinator, a specially trained person with knowledge of the donation, procurement, and transplantation process, typically speaks to family members about organ donation and answers their questions. Contact is permitted after the procedure with consent from the donor's family and the recipient. Typically, the transplant organization coordinates the communication. Confidentiality of the potential donor is always maintained unless the recipient and donor families both sign confidentiality waivers.
A patient recently diagnosed with pancreatic cancer asks the nurse not to share the diagnosis with her family members. After visiting the patient, the patient's daughter approaches the nurse and states, "Mom just did not seem herself today. Are biopsy reports back and do they confirm pancreatic cancer?" What is the best response from the nurse to patient's daughter? a) It is unethical and illegal for me to discuss your mother's medical information with you. b) It is illegal for me to discuss biopsy results with anyone but the patient involved. c) It is unethical and illegal for me to give you the biopsy results; please ask your mother. d) It is unethical of me to discuss biopsy results with anyone but the patient involved.
It is unethical and illegal for me to discuss your mother's medical information with you. Explanation: Providing a firm response in explaining the need to protect patient information is one strategy to aid the nurse in ethical decision-making. The U.S. Department of Health and Human Services (DHHS) provides for patient confidentiality. Violations of a patient's confidentiality could result in criminal or civil litigation. While it is unethical/illegal to discuss biopsy results with the daughter, statements by the nurse indicating biopsy results are back but cannot be shared indirectly provide the daughter with confidential information. Encouraging the daughter to ask her mother about the biopsy results indirectly provides the daughter with information that the mother knows the biopsy results.
Which of the following situations is an example of battery that the nurse may experience while performing her nursing duties at the health care facility? a) Witnessing a procedure done on client without his consent b) Performing a surgical procedure without getting consent c) Taking the client's photographs without consent d) Telling the client that he cannot leave the hospital
Performing a surgical procedure without getting consent Explanation: Performing a surgical procedure without the client's consent is an example of battery. To protect health care workers from being charged with battery, adult clients are asked to sign a general permission for care and treatment during admission and additional written consent forms for tests, procedures, or surgery. Telling the client not to leave the hospital is a false imprisonment. Taking the client's photographs without his permission and witnessing a procedure done on him without consent is violation of the client's privacy.
An elderly client who has been diagnosed with delusional disorder for many years is exhibiting early symptoms of dementia. His daughter lives with him to help him manage daily activities, and he attends a day care program for seniors during the week while she works. A nurse at the day care center hears him say, "If my neighbor puts up a fence, I will blow him away with my shotgun. He has never respected my property line, and I have had it!" Which action should the nurse take? a) Report the comment to the client's daughter so she can observe him more closely, but refrain from telling the neighbor due to privacy regulations. b) Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. c) Observe the client more closely, but do not report his threat since he will likely not be able to follow through with it because of his dementia. d) Report the comment to the neighbor, the intended victim, but refrain from telling the daughter since she will just worry about actions of her father she cannot control.
Report the comment to the neighbor, the daughter, and the police since there is the potential for a criminal act. Explanation: The neighbor could be harmed as well as the daughter if she should try to stop her father from using the gun, so both should be notified. Any use of firearms against another person requires the involvement of the police. The nurse has a legal/ethical responsibility to warn potential victims and other involved parties as well as law enforcement authorities when one person makes a threat against another person. This duty supersedes confidentiality statutes. Failure to do so and to document it can result in civil penalties. The client's early dementia would likely not prevent him from carrying through his threat.
A hospitalized patient asks the nurse for "some aspirin for my headache." There is no order for aspirin for this patient. What will the nurse do? a) Ask the patient's family to bring some aspirin from home. b) Go ahead and give the patient aspirin, a common self-prescribed drug. c) Ask the patient's visitors if they have any aspirin for the patient. d) State that an order from the doctor is legally required and check with the doctor.
State that an order from the doctor is legally required and check with the doctor. Explanation: No medication may be given to a patient without a medication order from a physician (or a nurse practitioner in some states). The nurse would tell the patient an order from the physician is required.
An advanced practice registered nurse (APRN) specializing in adult-gerontology has accepted a new position in a different state. Which governing body does the APRN need to consult to verify prescriptive authority in the new state? a) The new states boards of nursing b) The new states APRN Advisory Committee c) The new employers' board of directors d) The National Council of State Boards of Nursing (NCSBN)
The new states boards of nursing Explanation: Individual states have their own distinct state boards of nursing (and sometimes state boards of medicine) regulations that govern APRN practice. Individual states do not have APRN advisory committees. The APRN Consensus Model promotes a new APRN regulatory model that addresses the essential elements of APRN licensure, accreditation, certification, and education (LACE). The NCSBN provides state boards of nursing an organization allowing them to act and counsel together on matters of common interest related to the public health, safety and welfare, including the development of licensing examinations in nursing. The board of directors guides nursing care within the rules for nursing practice established by the State Board of Nursing.
A client is received in a postoperative nursing unit after undergoing abdominal surgery. During this time, the nurse failed to recognize the significance of abdominal swelling, which significantly increased during the next 6 hours. Later, the client had to undergo emergency surgery. The lack of action on the nurse's part is liable for action. Which of the following legal terms describes the case? a) Misdemeanor b) Fraud c) Tort d) Felony
Tort Explanation: A tort is a litigation in which one person asserts that a physical, emotional, or financial injury was a consequence of another person's actions or failure to act. The lack of action on the nurse's part truly indicates unintentional tort. A misdemeanor or felony would be an offense under criminal law, and neither is applicable in this case. Fraud is willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property.
A nursing instructor is discussing a nursing student's Facebook post about a very interesting client situation that happened during clinical. The student states, "I didn't violate client privacy because I didn't use the client's name." What response by the nursing instructor is most appropriate? a) "All aspects of the clinical experience are confidential and should not be discussed." b) "The information being posted on Facebook is inappropriate. Make sure to discuss information about client's privately with friends and family." c) "You may continue to post about client you cared for during clinicals, as long as you do not use the client's name." d) "Any information that can identify a person is considered a breach of client privacy."
"Any information that can identify a person is considered a breach of client privacy." Explanation: Any information that can identify a person is considered confidential. A medical condition may identify a client that was cared for, especially if the location of the clinical site and unit was disclosed in the post. Discussion of clinical experience can be used for teaching purposes or seeking advice on care. No care should be discussed, even privately, with friends and family.
What is the nurse expected to do when filing a report about an incident of finding an elderly client with mild dementia on the floor? a) The nurse is aware that adverse reports are not confidential material, so only documentation in the chart should be completed. b) The nurse must chart about the incident and communicate in a report about the event. c) The nurse must file an incident or adverse event report. d) The nurse must communicate the event to the charge nurse, who will document the fall in an adverse reporting system.
The nurse must file an incident or adverse event report. Explanation: Nurses who witnessed the event are responsible for entering the information. Adverse reporting is a mechanism to find persistent problems; it is confidential and nonpunitive.
A 79-year-old male patient who is postoperative day three following hip replacement surgery has been approached by a nurse researcher and asked to participate in a research study that will test a new rehabilitation strategy. What aspect of the nursing research process addresses the patient's understanding of the potential risks and benefits of this study? a) Giving the patient the opportunity to ask questions about the study b) Obtaining the patient's witnesses signature on a permission document c) Going through the informed consent process with the patient d) Meeting with the hospital's institutional review board (IRB)
Going through the informed consent process with the patient Explanation: Informed consent is a process in which the details of the study and the patient's rights are explained and discussed in detail. This goes beyond simply obtaining the patient's signature or allowing him to ask questions. Meeting with the IRB is a necessary step in the research process but this does not directly affect the patient's understanding of risks and benefits.
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? a) Having the client sign a consent form for the procedure b) Inserting a Foley catheter the morning of the procedure c) Maintaining the client without liquids before the procedure d) Explaining to the client that the procedure will be painful
Having the client sign a consent form for the procedure Explanation: The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.
The nurse is participating in a discussion about controlled substances. Which statement, made by the nurse, indicates the nurse is aware of laws governing the distribution of controlled substances? a) Nurses are responsible for adhering to specific documentation about controlled substances.? b) The nurse is only at risk if she diverts medication from the client; using personal drugs decrease your risk.? c) An impaired nurse is promptly punished by being terminated and having his or her license suspended.? d) "When a nurse abuses controlled substances in the workplace and gets help, she will not be charged with a criminal act."
Nurses are responsible for adhering to specific documentation about controlled substances.? Explanation: Nurses have specific responsibilities regarding controlled substances, including specific documentation. Violation of controlled substances at the workplace is serious and is considered a criminal act. Substance abuse is treatable and the objective is to detect and treat the problem early. It does not matter where the nurse obtains the drugs; she is still liable for her actions.
A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. Which of the following should happen in this case? a) The client should be resuscitated if he experiences respiratory arrest. b) The wishes of his family should be followed. c) Pharmacologic interventions should not be initiated. d) The client should be treated with antibiotics for pneumonia.
The client should be treated with antibiotics for pneumonia. Explanation: The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.
A client is having elective surgery under general anesthesia. Who is responsible for obtaining the informed consent? a) The anesthesiologist. b) The surgeon. c) The nurse. d) The nurse anesthetist.
The surgeon. Explanation: It is the role of the surgeon or the person performing the procedure to obtain the informed consent. This consists of informing the client about the procedure, the risks of treatment, the side effects, other types of treatments available, and the effects without the procedure.
A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to: a) ask security to remove the boyfriend from his estranged wife's hospital room. b) see the neonate through the nursery glass window. c) decide to circumcise his son. d) hold the neonate after the mother gives permission.
hold the neonate after the mother gives permission. Explanation: The neonate's mother has legal control over the neonate. Therefore, the mother must grant permission for her estranged partner to hold him. The neonate commonly stays in the mother's room, not in the nursery. Therefore, looking through the nursery window isn't an option. The estranged partner can't ask to have the boyfriend removed because the client wants him to remain. The mother must sign the consent for circumcision.
An HIV-positive client discovers that his name is published in a report on HIV care prepared by his nurse. He strongly opposes this and files a lawsuit against the nurse. Which of the following offenses has this nurse committed? a) Unintentional tort. b) Invasion of privacy. c) Negligence of duty. d) Defamation.
Invasion of privacy. Explanation: The nurse has committed the tort of invasion of privacy. Personal names and identities are concealed or obliterated in case studies or research work. Invasion of privacy is a type of intentional tort. Defamation is an act in which untrue information harms a person's reputation, and is therefore not applicable here. Negligence is the harm that results because a person did not act reasonably.
What is true of nursing responsibilities with regard to a physician-initiated intervention (physician's order)? a) Nurses are responsible for reminding physicians to implement orders. b) Nurses do carry out interventions in response to a physician's order. c) Nurses do not carry out physician-initiated interventions. d) Nurses are not legally responsible for these interventions.
Nurses do carry out interventions in response to a physician's order. Explanation: A physician-initiated intervention is initiated in response to a medical diagnosis but carried out by a nurse in response to a doctor's order. Both the physician and the nurse are legally responsible for these interventions. (less)
A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. Which of the following responses by the nurse overhearing the conversation would be best? a) Telling the mother what was being said about her. b) Reporting this incident to the nurse-manager. c) Talking to the staff in general about confidentiality. d) Talking to the staff member privately about this.
Talking to the staff member privately about this. Explanation: The best approach is to talk to the staff member privately about the information that the mother shared. This information is confidential and should not be disclosed. Reporting the incident to the nurse-manager is appropriate once the nurse has spoken to the staff member privately. Although it may be tempting to tell the mother, talking to the staff member privately is the best approach because trust between the staff nurse and mother needs to be maintained. Talking to the staff in general about confidentiality may be beneficial. However, the nurse needs to speak with the staff member in private first.
Choice Multiple question - Select all answer choices that apply. The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply. a) A 16-year-old who is obtaining an elective breast reduction for back pain relief b) A 72-year-old widow with dementia who needs a mastectomy for cancer removal c) A married 17-year-old who requires a cholecystectomy for relief of nausea and pain d) A 7-year-old who needs an open reduction internal fixation (ORIF) of the right arm e) A 62-year-old with macular degeneration who is ordered a routine colonoscopy
• A married 17-year-old who requires a cholecystectomy for relief of nausea and pain • A 62-year-old with macular degeneration who is ordered a routine colonoscopy Explanation: There are many factors for the nurse to consider when evaluating whether a client can consent to surgery. These include being: mentally ill or disabled, a minor, under the influence of alcohol, drugs, or medication, in labor, under great stress or in pain at the time of consent, in a semi-conscious state. The 7 and 16 year old are minors while the 17 year old is married and an emancipated minor and able to give consent. Having difficulty seeing due to macular degeneration does not preclude the ability to have the consent read and then provide consent. Depending upon the severity of the dementia, the client will need to be evaluated for competence before independently providing consent.
Choice Multiple question - Select all answer choices that apply. A nurse is explaining the preparation of a death certificate to a student nurse. Which statements accurately describe this process? (Select all that apply.) a) Death certificates are sent to a national health department, which compiles many statistics from the information. b) A physician's signature is required on a death certificate. c) It is the nurse's responsibility to ensure that the physician has signed a death certificate. d) U.S. law requires that a death certificate be prepared for each person who dies. e) The nurse assumes responsibility for handling and filing the death certificate with the proper authorities. f) A death certificate is signed by the pathologist, the coroner, and others in special cases.
• U.S. law requires that a death certificate be prepared for each person who dies. • A physician's signature is required on a death certificate. • It is the nurse's responsibility to ensure that the physician has signed a death certificate. • A death certificate is signed by the pathologist, the coroner, and others in special cases. Explanation: Death certificates are required in all deaths in the U.S., must be signed by a physician, and the pathologist or coroner. The nurse must ensure that death certificates are signed. Death certificates are sent to local health departments. The mortician handles and files death certificates.
Your 90-year-old home care client designated her son to make decisions regarding her medical care when she is no longer able to do so. As she nears the end of her life, her son is consulted on an ever-increasing basis. What is the name of the legal instrument that activates her son's decision-making designation? a) Power of attorney b) Designated signer c) Living will d) Durable power of attorney
Durable power of attorney Explanation: A durable power of attorney (DPOA) for healthcare or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. It allows competent clients to identify exactly what life-sustaining measures they want to be implemented, avoided, or withdrawn and offers reassurance that others will carry out their wishes. This is a legal term used in a different context; a durable power of attorney (DPOA) for healthcare or healthcare proxy is the person the client designates to make medical decisions on the client's behalf when the client no longer can do so. A living will is a written or printed statement describing a person's wishes concerning medical care and life-sustaining treatments that are wanted or unwanted in the event that a person is unable to personally make those decisions. Althougha living will describes a person's wishes, it does not designate decision-making power to another person in the same was as a DPOA. This is not a term used in healthcare.
A nurse on a night shift entered an elderly patient's room during a scheduled check and discovered the patient down on the floor beside her bed after falling when trying to ambulate to the washroom. After assessing the patient and assisting her back to bed, the nurse has completed an incident report. What is the primary purpose of this particular type of documentation? a) Following up the incident with other members of the care team b) Identifying risks and ensuring future safety for patients c) Protecting the nurse and the hospital from litigation d) Gauging the nurse's professional performance over time
Identifying risks and ensuring future safety for patients Explanation: Incident reports are used for quality improvement by identifying risks and should not be used for disciplinary action against staff members. They are not primarily motivated by the need to protect care providers or institutions from legal action, and they are not commonly used to communicate within the interdisciplinary team
A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case? a) Do not restrain the client, as it is equivalent to battery. b) Inform the physician and complete a comprehensive assessment. c) Restrain the client, as he is harmful to the other clients. d) Do not restrain the client, as it is equivalent to false imprisonment.
Restrain the client, as he is harmful to the other clients. Explanation: The nurse should restrain the client because he is potentially harmful to other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client. (less) Remediation: Restraints use for assaultive and violent behavior
A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality? a) Place the documents in the client's chart. b) Leave the documents at the nurses' station. c) Shred the documents or place them in a container to protect confidentiality. d) Throw the documents in the trash can.
Shred the documents or place them in a container to protect confidentiality. Explanation: Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special confidential container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.
A nurse, while off-duty, tells the physiotherapist that a client who was admitted to the nursing unit contracted AIDS due to exposure to sex workers at the age of 18. The client discovers that the nurse has revealed the information to the physiotherapist. With what legal action could the nurse be charged? a) Negligence b) Slander c) Malpractice d) Libel
Slander Explanation: The nurse can be charged with slander, which is a verbal attack on a person's character. Libel pertains to damaging written statements read by others. Both libel and slander are considered defamation of character - an intentional tort in which one party makes derogatory remarks about another that diminish the other party?s reputation. Negligence and malpractice pertain to actions which are committed or omitted, thereby causing physical harm to a client.
When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? a) While bathing a client behind pulled curtains, two nurses are discussing a different client. b) The nurse tells the client she cannot leave the hospital because she is seriously ill. c) The staff nurse threatens to restrain the client if she did not take her medication. d) The elderly client refuses the intramuscular injection, but the staff nurse administered it.
The elderly client refuses the intramuscular injection, but the staff nurse administered it. Explanation: If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening a client is assault. Discussing another client within earshot of others is an invasion of privacy. Keeping a client against her wishes, regardless of her health status, is false imprisonment
When making client rounds, the charge nurse observes which action by a staff nurse that would constitute battery? a) The nurse tells the client she cannot leave the hospital because she is seriously ill. b) While bathing a client behind pulled curtains, two nurses are discussing a different client. c) The staff nurse threatens to restrain the client if she did not take her medication. d) The elderly client refuses the intramuscular injection, but the staff nurse administered it.
The elderly client refuses the intramuscular injection, but the staff nurse administered it. Explanation: If the client refuses a procedure or medication and the nurse proceeds with it, it is battery. Threatening a client is assault. Discussing another client within earshot of others is an invasion of privacy. Keeping a client against her wishes, regardless of her health status, is false imprisonment.
