A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

The nurse establishes rapport with the client in an inpatient psychiatric setting.

The nurse documents accurately and honestly in the electronic health record.

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission.

The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.

Answer and Explanation

The Correct Answer is C

The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.

Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.

Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.

Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Ask the client to describe the discomfort. This is the best action to establish a nursing diagnosis of pain related to an abdominal incision because it allows the nurse to assess the location, intensity, quality, and duration of the pain, as well as any factors that aggravate or relieve it.

This information can help the nurse to plan appropriate interventions and evaluate their effectiveness.

Choice A. Continue to observe the client is wrong because it does not address the client’s pain or communicate empathy. The nurse should not ignore or minimize the client’s pain, but rather acknowledge it and offer assistance.

Choice C. Encourage the client to progressively relax all muscle groups is wrong because it is a nonpharmacological intervention that may help to reduce pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before implementing any interventions.

Choice D. Administer the prescribed analgesic and document the client’s response is wrong because it is a pharmacological intervention that may help to relieve pain, but it does not establish a nursing diagnosis of pain. The nurse should first assess the client’s pain before administering any medications.

A. Wipe from the outer part of the eye toward the inner portion. B. Rinse the washcloth before washing the second eye. C. Ask the client to roll the eyes upward. D. Use a fresh washcloth when cleaning each eye.

Correct Answer is D

Explanation

Use a fresh washcloth when cleaning each eye. This is because using the same washcloth for both eyes can transfer microorganisms from one eye to the other and cause cross-infection.

The other choices are wrong because:

Choice A is wrong because wiping from the outer part of the eye toward the inner portion can introduce microorganisms into the tear ducts and cause infection.

Choice B is wrong because rinsing the washcloth before washing the second eye does not eliminate all the microorganisms that might be on the cloth.

Choice C is wrong because asking the client to roll the eyes upward does not prevent spreading organisms from one eye to the other when bathing a client.

Normal ranges for eye hygiene are to use a clean washcloth or cotton ball for each eye, wipe from the inner to the outer canthus, and use warm water or saline solution.

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A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For a client who is crying and seems agitated after major abdominal surgery, which action should a nurse take to establish a nursing diagnosis of pain related to an abdominal incision?

Correct Answer is B

Explanation

Which action will prevent spreading organisms from one eye to the other when bathing a client?

Correct Answer is D

Explanation

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