An older adult client who is competent to make their own decisions is refusing to get the influenza vaccine.
The nurse comes back in 15 minutes and says that she has the client's Vitamin B12 injection but really gives the client an influenza vaccine.
This is an example of:
Negligence.
Battery.
False Imprisonment.
Assault.
The Correct Answer is B
Choice B rationale
Battery is the intentional and wrongful physical contact with a person without their consent. In this scenario, the nurse knowingly administered a vaccine that the competent client had explicitly refused. By disguising the vaccine as a different medication, the nurse bypassed the client's right to autonomy and performed an unauthorized procedure. Even though the nurse's intent might have been to protect the client's health, the physical act of injecting the vaccine against their will constitutes battery.
Choice A rationale
Negligence is a failure to provide the standard of care that a reasonably prudent person would have provided in a similar situation, resulting in unintended harm. This case does not represent negligence because the nurse's actions were intentional rather than a mistake or an oversight. The nurse purposefully deceived the client to administer the vaccine. Because the act was deliberate and involved unauthorized physical contact, it falls under the category of an intentional tort rather than negligence.
Choice C rationale
False imprisonment occurs when a person is restricted in their personal movement without legal justification or consent. This could involve physical restraints, chemical restraints, or threats that prevent a client from leaving a specific area. While the nurse's action in this scenario was unethical and illegal, it did not involve the restriction of the client's movement or freedom to leave. Therefore, the situation is classified as an issue of unauthorized contact rather than confinement or imprisonment.
Choice D rationale
Assault is an intentional act that creates a reasonable apprehension or fear of imminent harmful or offensive contact. It is often the threat of performing an act without the actual contact taking place. In this case, the nurse actually followed through with the injection by deceiving the client. Since the physical contact occurred, the legal definition moves beyond assault and into battery. Assault would have been if the nurse threatened to give the shot against the client's will.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
A blood pressure of 128/80 mmHg is considered within the normal to slightly elevated range according to current cardiovascular guidelines. Normal blood pressure is generally defined as less than 120/80 mmHg. Lisinopril, an ACE inhibitor, is indicated for hypertension and would typically be administered at this level to maintain therapeutic control. There is no clinical indication of hypotension at this reading, so holding the medication would be inappropriate for this client.
Choice B rationale
A blood pressure of 146/70 mmHg indicates isolated systolic hypertension. The systolic pressure is significantly above the target range of less than 120 mmHg. Administering lisinopril is necessary here to reduce systemic vascular resistance and lower the blood pressure toward a safer therapeutic goal. Holding the medication at this level would allow the hypertension to persist, increasing the risk of long-term vascular damage or acute cardiac events for the client.
Choice C rationale
A blood pressure of 102/58 mmHg is nearing the threshold for hypotension, which is generally defined as a systolic pressure less than 90 mmHg or a diastolic less than 60 mmHg. For a client on antihypertensives like lisinopril, this low reading suggests that further vasodilation could cause symptomatic hypotension or decreased organ perfusion. The nurse should hold the dose and notify the provider to prevent a dangerous drop in blood pressure and syncope.
Choice D rationale
A reading of 110/82 mmHg is considered a normal or pre-hypertensive blood pressure. It does not meet the criteria for hypotension that would warrant holding a scheduled cardiac medication. Lisinopril works by inhibiting the angiotensin-converting enzyme, which prevents the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. At 110/82 mmHg, the client is stable, and the medication is likely working effectively to maintain these desired cardiovascular parameters.
Correct Answer is A
Explanation
This phenomenon is known as molecular mimicry, where the structure of a foreign antigen closely resembles that of a host protein. The resulting cross-reactivity causes the immune system to erroneously attack healthy tissues. An example is rheumatic fever, where antibodies against Streptococcus also target cardiac valves.
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