A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment

Invasion of privacy

Assault

Battery

Answer and Explanation

The Correct Answer is A

A.   False imprisonment occurs when a person is intentionally confined or restrained against their will, and they have not given consent. In this scenario, if the nurse restrains the client against her will, it would be considered false imprisonment.
B.   Invasion of privacy involves intruding into a person's private affairs, disclosing private information, or using their name or likeness without their consent. This option is not applicable in this scenario.
C.   Assault is the intentional threat of causing harm to another person, which creates a reasonable fear of imminent harmful or offensive contact. It involves the apprehension of harm, but not the actual physical act.
D.   Battery is the intentional harmful or offensive touching of another person without their consent. It involves the actual physical act of touching.

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Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

A. Increased fiber in the diet B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased activity E. Excessive laxative use

Correct Answer is ["B","C","E"]

Explanation

A. Increased fiber in the diet is not a cause of constipation, but rather a preventive measure that can help promote regular bowel movements by adding bulk and softness to the stool.
B. Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of fecal matter in the colon, resulting in difficulty and pain during defecation.
C. Inadequate fluid intake is a cause of constipation, as it can contribute to dehydration and reduced stool moisture, making it harder and drier to pass.
D. Increased activity is not a cause of constipation, but rather a beneficial factor that can stimulate intestinal motility and facilitate bowel elimination.
E. Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependence, leading to decreased bowel tone and reduced peristalsis.

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development?

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform? (Select all that apply.)

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)