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 D
Explanation
Rationale:
A. Capillary refill time of 4 seconds is concerning but less urgent compared to immediate post-catheter removal issues.
B. Fruity breath odor in late-stage cirrhosis could indicate a metabolic issue but is less immediate than issues related to urinary output.
C. Green gastric aspirate with a pH of 5.3 is within normal range for NG tube decompression.
D. A client who has not voided 5 hours after catheter removal is at risk for urinary retention or other complications and should be assessed immediately.
Correct Answer is B
Explanation
Rationale:
A. Identifying changes within the family unit can be important but is not the immediate priority for medical stabilization.
B. Gaining weight is a critical goal for clients with anorexia nervosa to address their physical health and nutritional status.
C. Making positive statements about body image is helpful but secondary to the goal of weight gain.
D. Feeling in control of behavior is important for long-term recovery but is not the immediate priority compared to physical health.