A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?
The nurse informs the client that the behavior will not be tolerated and will be addressed by the psychiatrist.
The nurse throws the medication in the trash and documents the client refuses the medication.
The nurse pushes the client, and the client falls to the floor and sustains a nosebleed.
The nurse goes to the client's room and applies restraints, then forces the medication in the client's mouth.
The Correct Answer is D
Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.
Options A, B, and C are not examples of false imprisonment:
A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.
B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.
C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["260"]
Explanation
Step 1: Convert ½ cup of juice to mL. 1 cup = 240 mL ½ cup = 240 mL ÷ 2 = 120 mL Result: 120 mL
Step 2: Convert 3 oz of gelatin to mL. 1 oz = 30 mL 3 oz = 3 × 30 mL = 90 mL Result: 90 mL
Step 3: Convert 1 oz of an ice pop to mL. 1 oz = 30 mL 1 oz = 1 × 30 mL = 30 mL Result: 30 mL
Step 4: Ginger ale is already in mL. Result: 20 mL
Step 5: Add all the mL values together. 120 mL + 90 mL + 30 mL + 20 mL = 260 mL Result: 260 mL
The nurse should record the child’s fluid intake as 260 mL.
Correct Answer is ["A","D","E"]
Explanation
The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:
A. Prior to performing any intervention that requires touch, the nurse will ask permission.
This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.
D. The nurse will perform a continuous assessment of the client's anxiety level.
Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.
E. Have security present outside of the client's room to prevent anyone from coming in.
Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.
It is not appropriate to:
B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.
C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.
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