While caring for a client near end of life, a nurse talks to the client. An unlicensed assistive personnel asks why the nurse is talking to someone who is dying. Which response is accurate?

Choice A reason: Falsifying vital signs by documenting earlier readings without reassessment constitutes fraud, a deliberate misrepresentation that could harm the patient. Accurate vital signs monitor physiological status, like heart rate or blood pressure, ensuring stability for discharge. Fraudulent documentation risks missing critical changes, such as tachycardia or hypotension, potentially leading to unsafe discharge and legal liability.

Choice B reason: False imprisonment involves unlawfully restricting a patient’s movement, unrelated to falsifying vital signs. Documentation errors do not restrict mobility but compromise care quality. Vital signs reflect cardiovascular and respiratory function, and falsifying them risks patient safety, not freedom, making false imprisonment an incorrect tort for this scenario of fraudulent charting.

Choice C reason: Battery involves unauthorized physical contact, like unconsented procedures, not documentation errors. Falsifying vital signs is a non-physical act of misrepresentation, not touching. Accurate vital signs ensure physiological stability for discharge, and falsification risks harm through neglect, aligning with fraud, not battery, as the nurse’s action involves deceit, not contact.

Choice D reason: Assault involves threatening harm, not falsifying records. Documenting earlier vital signs without reassessment is fraudulent, risking patient safety by missing physiological changes, like arrhythmias. This misrepresentation does not involve threats or intimidation, making assault irrelevant. Fraud is the appropriate tort, as it addresses intentional deception in clinical documentation.

Choice A reason: Urinary status, such as output, monitors hydration and kidney function post-surgery but is unrelated to safe oral intake. Abdominal surgery risks paralytic ileus, where intestinal motility ceases, increasing aspiration risk if food is consumed. Bowel sounds indicate gastrointestinal function recovery, making urinary status a secondary consideration for dietary decisions.

Choice B reason: Skin turgor assesses hydration but does not determine readiness for oral intake post-surgery. Abdominal surgery can impair peristalsis, causing ileus, which risks vomiting or obstruction if food is introduced prematurely. Assessing bowel sounds confirms intestinal motility, critical for safe eating, while skin turgor is irrelevant to gastrointestinal recovery.

Choice C reason: Pain level is important for patient comfort but not the primary consideration for eating post-surgery. Pain may indicate complications, but absent bowel sounds suggest ileus, a condition where the gut lacks motility, risking aspiration. Bowel sounds confirm peristalsis, ensuring safe digestion, making pain a secondary factor in this context.

Choice D reason: Bowel sounds indicate gastrointestinal motility, critical after abdominal surgery to prevent complications like ileus. Absent sounds suggest impaired peristalsis, increasing risks of vomiting or obstruction if food is consumed. Auscultating active bowel sounds confirms the gut’s readiness to process food, making this the primary consideration before allowing eating to ensure safety.