A nurse is caring for a client who is exhibiting increased agitation. The nurse offered toileting, lowered the lights in the client's room and closed door to client's room.
Complete the following sentence by using the lists of options.
The nurse is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
False Imprisonment: This refers to the unlawful restraint of an individual's freedom of movement. By applying wrist restraints without a clear and immediate order from a provider or without proper justification, the nurse could be restricting the client's freedom of movement inappropriately.
Applying wrist restraints to the client: This action is a key factor in the potential for false imprisonment. Restraints should be used only when necessary and with proper authorization and documentation, particularly in non-emergency situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Assisting a client to cough and deep breathe is a task that can be performed by an AP under supervision.
B. Application of antiembolic stockings is within the scope of APs, though it may be monitored by an RN.
C. Administration of an enema typically requires nursing judgment and assessment, making it more appropriate for the RN.
D. Assessing a client’s sacrum for edema requires clinical assessment skills and nursing judgment, which should be performed by an RN.
Correct Answer is D
Explanation
Rationale:
A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.
B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.
C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."
D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.
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