On finding multiple bruises on a client's arms and back, the nurse suspects that the client is being abused by a daughter who lives with the client. When questioned, the client denies any abuse. Despite the client's denial, the nurse should report the suspected abuse on the basis of which rationale?

The nurse wants peers to see the nurse as a hero.

The nurse has a legal and ethical responsibility to report the suspected abuse.

The client does not want anyone to know what is happening in the client's home.

The client is ashamed to admit to the abuse by the daughter.

Answer and Explanation

The Correct Answer is B

A. Reporting for personal recognition is not appropriate or ethical.
B. Nurses are mandated reporters and have a legal and ethical duty to report suspected abuse.
C. While the client may not want others to know, the nurse's responsibility is to ensure the client's safety.
D. Although the client may feel ashamed, the priority is their safety and wellbeing.

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Correct Answer is C

Explanation

A. Battery involves actual physical contact without consent.
B. Negligence refers to failing to provide reasonable care, resulting in harm.
C. Assault is threatening to harm or perform a procedure without consent, which the nurse is doing by threatening to hold the client down.
D. Defamation involves damaging someone's reputation through false statements.

A. Bathe a client who had an amputation 2 days ago. B. Assist a client to ambulate using a gait belt. C. Feed a client who had a stroke 3 months ago. D. Review a low-sodium diet for a client who has hypertension. E. Explain oral hygiene to a client receiving chemotherapy.

Correct Answer is ["A","B","C"]

Explanation

A. Bathing a client who had an amputation 2 days ago can be safely delegated to assistive personnel (AP) as it does not require specialized nursing knowledge.
B. Assisting a client to ambulate using a gait belt is within the scope of practice for assistive personnel (AP) and helps promote mobility.
C. Feeding a client who had a stroke 3 months ago can be delegated to assistive personnel (AP) as it involves activities of daily living.
D. Reviewing a low-sodium diet for a client with hypertension requires nursing judgment and should not be delegated to assistive personnel (AP).
E. Explaining oral hygiene to a client receiving chemotherapy requires nursing knowledge and should not be delegated to assistive personnel (AP).

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client refuses to have pain medication administered by injection. The nurse states, "If you don't let me give you the shot, I will get help to hold you down and give it." What tort may the nurse be committing?

Correct Answer is C

Explanation

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse using the principle-based approach to client care seeks to avoid causing harm to clients in all situations. What is this principle known as?

A nurse is caring for a client who has a mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete?

A nurse checks with assistive personnel on the unit throughout the shift to determine if they are completing tasks. The nurse is demonstrating which of the following rights of delegation?

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

A nurse in a long-term care facility is planning care for several clients. Which of the foll wing activities should the nurse delegate to the licensed practical nurse (LPN)?

Which is an example of nonmaleficence?