A nurse is caring for a client who refuses to follow the provider's prescription for strict bed rest. The nurse overhears an assistive personnel (AP) telling the client, "If you do not remain in bed, I will place you in restraints." The nurse should identify that the AP is committing which of the following torts?

False imprisonment

Defamation of character

Battery

Assault

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B, C, E, D, A

Explanation

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort

A. "New dressing applied as prescribed; no drainage on old dressing." B. "Client premedicated with MSO, sub prior to dressing change." C. "The wound seems clean and does not appear to be infected." D. "No changes noted to the wound from previous nursing notes."

Correct Answer is A

Explanation

Choice A reason:
"New dressing applied as prescribed; no drainage on old dressing. “This entry provides clear and concise information about the action taken (applying a new dressing as prescribed) and the assessment of the old dressing (no drainage present). It accurately reflects the dressing change process and the status of the wound.
Choice B reason:
"Client premedicated with MSO, sub-prior to dressing change." This entry is incorrect because it provides information about the client being premedicated, but it doesn't specifically address the dressing change or the pressure injury.
Choice C reason:
"The wound seems clean and does not appear to be infected." While this entry provides an assessment of the wound's cleanliness and potential infection, it lacks specific details about the dressing change itself.
Choice D reason:
"No changes noted to the wound from previous nursing notes." This entry focuses on comparing the wound to previous notes but doesn't provide information about the current dressing change or assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B, C, E, D, A

Explanation

A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrates correct documentation?

Correct Answer is A

Explanation

A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?

A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? (Select all that apply.)

A nurse is documenting client care. Which of the following abbreviations should the nurse use?

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?