A nurse is caring for a client who is confused and uncooperative. The client hit the nurse when she attempted to give him his medication. The nurse asks the charge nurse if she can restrain the client. The charge nurse should tell the nurse this action is a violation of the client's rights and is an example of which of the following?
Defamation of character
Slander
False imprisonment
Invasion of privacy
The Correct Answer is C
Rationale:
A. Defamation of character involves damaging someone’s reputation, which is not relevant in this context.
B. Slander involves spoken defamation, not applicable here.
C. False imprisonment refers to the unlawful restraint or restriction of an individual’s freedom, which can occur with unauthorized use of restraints.
D. Invasion of privacy involves unauthorized access to personal information or space, not directly related to the use of restraints.
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Correct Answer is A
Explanation
Rationale:
A. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.
B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.
C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.
D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.
Correct Answer is B
Explanation
Rationale:
A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output requires assessment for possible drug reaction or hematuria, but this may not be immediately life-threatening compared to hypoglycemia.
B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL is at risk for hypoglycemia, which requires prompt assessment and intervention to prevent severe complications.
C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache should be assessed, but the calcium level and headache are less urgent compared to immediate treatment needs for hypoglycemia.
D. A client who was administered acyclovir for cellulitis reports pain in the affected leg may require assessment for infection or medication side effects, but this is less critical than addressing hypoglycemia.