A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist.

The nurse throws the medication in the trash and documents the client refuses the medication.

The nurse pushes the client, and the client falls to the floor and sustains a nosebleed.

The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth.

Answer and Explanation

The Correct Answer is D

Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.

Options A, B, and C are not examples of false imprisonment:

A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.

B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.

C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.

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Correct Answer is A

Explanation

The potential issue that the nursing staff and hospital may have to defend against in this scenario is A. "malpractice."

Explanation: Malpractice refers to a legal claim that can be made against healthcare professionals, including nurses and hospitals, when they fail to provide the standard of care expected in their profession, resulting in harm or injury to a patient. In this case, the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression, especially one at risk for self-harm or suicide. If the client attempted suicide in the bathroom and sustained an injury, it could be argued that the lack of proper assessment and monitoring contributed to the client's harm, and this failure to provide appropriate care might be considered malpractice.

The other options, "battery," "false imprisonment," and "assault," do not directly relate to the situation described in the scenario:

B- Battery refers to the intentional harmful or offensive contact with a person without their consent. There is no indication that this occurred in the scenario.

C- False imprisonment refers to the unlawful restraint or restriction of a person's freedom of movement without proper justification. There is no indication of false imprisonment in the scenario.

D- Assault refers to the intentional act of threatening or causing fear of harm to another person. While the client did sustain an injury, there is no indication that it was due to an intentional act of assault in this scenario.

In summary, the potential issue of malpractice arises from the failure to properly assess and monitor a client at risk for self-harm, resulting in harm to the client. The nursing staff and hospital may have to defend against this claim if it is determined that they did not meet the standard of care expected in such a situation.

A. "We will have to talk about this later." B. "what happened that got you so upset?" C. "You really scared me. I'm glad you are okay." D. "Your behavior is unacceptable and will not be tolerated

Correct Answer is B

Explanation

When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.

The other options are inappropriate because:

A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.

C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.

D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.

Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.

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A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

Correct Answer is A

Explanation

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

Correct Answer is B

Explanation

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A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?