A charge nurse is observing a newly licensed nurse provide care for a client who is postoperative.

The newly licensed nurse tells the client that she will insert a urinary catheter if the client will not void.

Which of the following torts should the charge nurse identify as having occurred?

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling

Choice C rationale:

Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

The correct answer is: b. A room containing personal belongings.

Choice A rationale: A room without a window may lead to disorientation and a lack of natural light, which can disrupt the client's circadian rhythm, contributing to sleep disturbances and mood alterations. Adequate exposure to natural light helps regulate the body's internal clock and promotes a sense of well-being. Furthermore, natural light exposure has been linked to improved cognitive function and mood stability in individuals with cognitive impairments. Therefore, choosing a room with a window is essential for optimizing the client's therapeutic environment.

Choice B rationale: A room containing personal belongings is crucial for creating a therapeutic environment for a cognitively impaired client. Familiar items provide a sense of security and continuity, reducing anxiety and agitation. These belongings serve as anchors to the client's past experiences and identity, facilitating reminiscence therapy and promoting emotional connection. By surrounding the client with familiar objects, the nurse fosters a sense of autonomy and self-expression, empowering the client to engage in meaningful activities and maintain a sense of personal agency.

Choice C rationale: While proximity to the nursing station may facilitate monitoring and prompt intervention in case of emergencies, a room adjacent to the nursing station can also expose the client to constant noise and disruptions. Excessive auditory stimuli can overwhelm a cognitively impaired individual, leading to sensory overload and exacerbating confusion and disorientation. Moreover, the lack of privacy in such a location may compromise the client's dignity and autonomy, hindering their ability to engage in personal activities and interactions. Therefore, placing the client in a quieter, more secluded environment away from the nursing station is preferable for promoting a therapeutic atmosphere conducive to rest and relaxation.

Choice D rationale: Dim lighting poses significant risks for cognitively impaired clients, as it impairs visual perception and increases the likelihood of accidents and falls. Inadequate lighting compromises safety by obscuring obstacles and hazards in the environment, heightening the risk of injuries and fractures. Additionally, dimly lit spaces can exacerbate feelings of fear and anxiety, particularly in individuals with cognitive impairments who may already experience sensory processing difficulties. Bright lighting, on the other hand, enhances visibility and spatial orientation, promoting independence and confidence in daily activities. Therefore, ensuring sufficient illumination in the client's room is essential for mitigating safety hazards and optimizing their overall well-being.