Which guideline does the nurse apply to discussion of sleep patterns with older adult clients?

Choice A rationale

Battery in a legal context refers to the intentional touching of another person without their consent. Inserting a urinary catheter into a client's urethra after the client has explicitly refused the procedure constitutes a non-consensual physical contact. Even if the procedure was ordered, the lack of consent transforms the act into battery, especially if it results in injury to the client.

Choice B rationale

Dereliction of duty, a component of negligence, involves a failure to meet the accepted standard of care. While inserting a catheter against a client's will could be seen as a failure in ethical and potentially professional standards, the specific tort of battery focuses on the unauthorized physical contact, regardless of whether it was done negligently or with intent to harm (though intent to touch without consent is present).

Choice C rationale

Assault involves an intentional act that creates a reasonable apprehension of immediate harmful or offensive contact. While the client may have felt threatened or apprehensive when the nurse proceeded despite their refusal, the actual insertion of the catheter and subsequent injury constitute battery, as physical contact occurred. Assault precedes battery; battery is the actual physical contact.

Choice D rationale

Invasion of privacy pertains to the wrongful intrusion into a person's private affairs or the public disclosure of private information. While a client has a right to privacy regarding their body and medical procedures, the act of physically inserting a catheter against their will, leading to injury, primarily constitutes a physical violation and lack of consent, which falls under the definition of battery.

Choice A rationale

Anticipatory Grieving is a normal response to an expected loss, such as the impending death of oneself or a loved one. While the client is facing death, her statement "Why me, Lord" and inability to pray suggest a struggle with her spiritual beliefs and meaning in the face of this event, rather than primarily focusing on the emotional preparation for loss.

Choice B rationale

Ineffective Coping refers to an inability to manage stressors effectively. While the client's distress indicates difficulty coping with her situation, the specific mention of spiritual questioning and inability to pray points towards a disturbance in her spiritual well-being, which is more accurately described by spiritual distress.

Choice C rationale

Low Self-Esteem involves negative feelings about oneself and one's worth. While facing death can impact self-esteem, the client's direct questioning of her faith and inability to connect spiritually are the more prominent indicators in this scenario, suggesting a conflict or disruption in her spiritual domain rather than primarily a devaluation of self.

Choice D rationale

Spiritual Distress is characterized by a disruption in one's belief or value system that provides strength, hope, and meaning to life. The client's cry of "Why me, Lord" and her inability to pray indicate a struggle with her faith and a potential feeling of abandonment or questioning of her spiritual beliefs in the face of death. This aligns directly with the defining characteristics of spiritual distress.