A nurse is caring for a client.

Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

1500:

Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.

1730:

Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.

Vital Signs

1730:

• Temperature 37.2° C (98.9° F)
• Blood pressure 168/84 mm Hg
• Heart rate 116/min
• Respiratory rate 24/min
• Oxygen saturation 93% on room air

Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.

Choice A reason:
Obtaining printed information about insulin self-administration is a first recommendation as it can be done after ensuring the client's ability to afford the supplies.
Choice B reason:
Making a copy of the medication reconciliation form for the client is not a first recommendation as it can be done after ensuring the client's access to supplies.
Choice C reason:
Determining whether the client can afford the insulin administration supplies is the first action to be taken. The first step should be to ensure that the client can afford the insulin administration supplies. Proper management of diabetes requires having access to the necessary equipment, including insulin, syringes, pens, or other devices. If the client cannot afford these supplies, alternative options or assistance programs may need to be explored to ensure the client's safety and well-being.
Choice D reason:
Providing the client with the contact number for a diabetes education specialist is important for long-term management, but addressing the affordability of supplies should take precedence initially.