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
Client 1 presents with stable vital signs. A temperature of 97.8 F, pulse of 66 bpm, respiratory rate of 14, and blood pressure of 122/72 mmHg are all within normal limits. An oxygen saturation of 97 percent is also excellent. This client is physiologically stable and does not require immediate intervention. The nurse should prioritize clients with abnormal respiratory parameters or signs of hypoxia over those who are maintaining normal homeostatic values and adequate oxygenation.
Choice B rationale
Client 2 has vital signs that are mostly within normal ranges. The temperature of 98.8 F and pulse of 82 are normal. A respiratory rate of 16 is ideal. The blood pressure of 130/62 mmHg shows a slightly widened pulse pressure but is not acutely concerning. The pulse oximetry of 95 percent is within the acceptable range for most adults. This client is stable and does not exhibit the acute respiratory distress seen in other potential candidates.
Choice C rationale
Client 3 is the priority because they are showing signs of respiratory distress and hypoxia. A respiratory rate of 28 breaths per minute is tachypneic (normal is 12 to 20), and an oxygen saturation of 90 percent is below the standard target of 95 to 100 percent. This indicates the client is struggling to maintain oxygenation and requires immediate assessment, potential oxygen therapy, and further diagnostic evaluation to prevent further respiratory failure or cellular hypoxia and related complications.
Choice D rationale
Client 4 demonstrates very stable vital signs. A temperature of 97.2 F, pulse of 70, and respiratory rate of 14 are normal. A blood pressure of 120/80 mmHg is the textbook definition of a normal reading. An oxygen saturation of 100 percent indicates perfect hemoglobin saturation. There is no clinical reason to see this client before Client 3, who is currently experiencing significant respiratory compromise and requires urgent nursing and possibly medical intervention.
Correct Answer is D
Explanation
Choice A rationale
Chest compressions are the primary component of cardiopulmonary resuscitation used to maintain perfusion during cardiac arrest. However, when a client has a documented Do Not Resuscitate order, performing compressions violates their legal and ethical right to refuse life-prolonging interventions. The nurse must honor the autonomy of the individual, especially when they have made a deliberate choice regarding their end-of-life care after being diagnosed with a terminal illness in a clinical setting.
Choice B rationale
Rapid response teams are typically summoned when a patient shows signs of clinical deterioration but still has a pulse and is breathing. Their goal is to prevent a full cardiac or respiratory arrest. Since this patient is already pulseless and has a DNR status, calling a rapid response team is inappropriate. The focus of care transitions from rescue to providing a dignified death, making the activation of an emergency response team unnecessary and contrary.
Choice C rationale
Pressing the Code Blue button initiates a full-scale resuscitation effort involving advanced cardiac life support protocols, intubation, and defibrillation. Initiating a code for a patient with a DNR status is a breach of nursing ethics and legal mandates. The nurse must prioritize the documented wishes of the client over hospital emergency protocols. Resuscitation efforts against a patient's known wishes can result in legal consequences and emotional distress for the grieving family members.
Choice D rationale
Honoring a DNR order is a fundamental aspect of providing patient-centered care and respecting self-determination. When a terminal patient experiences cardiac arrest, the nurse's role is to provide comfort and support rather than invasive medical intervention. This involves documenting the time of death, notifying the physician, and supporting the family. Refraining from lifesaving measures ensures that the client’s transition is peaceful and consistent with the healthcare goals they established before the event.
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