A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

Malpractice

Battery

False imprisonment

Assault

Answer and Explanation

The Correct Answer is A

The potential issue that the nursing staff and hospital may have to defend against in this scenario is A. "malpractice."

Explanation: Malpractice refers to a legal claim that can be made against healthcare professionals, including nurses and hospitals, when they fail to provide the standard of care expected in their profession, resulting in harm or injury to a patient. In this case, the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression, especially one at risk for self-harm or suicide. If the client attempted suicide in the bathroom and sustained an injury, it could be argued that the lack of proper assessment and monitoring contributed to the client's harm, and this failure to provide appropriate care might be considered malpractice.

The other options, "battery," "false imprisonment," and "assault," do not directly relate to the situation described in the scenario:

B- Battery refers to the intentional harmful or offensive contact with a person without their consent. There is no indication that this occurred in the scenario.

C- False imprisonment refers to the unlawful restraint or restriction of a person's freedom of movement without proper justification. There is no indication of false imprisonment in the scenario.

D- Assault refers to the intentional act of threatening or causing fear of harm to another person. While the client did sustain an injury, there is no indication that it was due to an intentional act of assault in this scenario.

In summary, the potential issue of malpractice arises from the failure to properly assess and monitor a client at risk for self-harm, resulting in harm to the client. The nursing staff and hospital may have to defend against this claim if it is determined that they did not meet the standard of care expected in such a situation.

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Correct Answer is C

Explanation

The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.

By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.

Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.

Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.

Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.

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.

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A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Correct Answer is C

Explanation

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Correct Answer is ["260"]

Explanation

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