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. This is the appropriate height to allow the fluid flow by gravity.
B. This is such a short distance and the fluid wouldn't flow as desired.
C. Holding the container at the client's upper hip would not provide the appropriate angle for administering the enema.
D. This choice does not provide specific guidance on the height or angle for administering the enema, which is crucial for the procedure's effectiveness.

A. Checking the pupillary response to light B. Eliciting the gag reflex C. Testing visual acuity D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Correct Answer is A

Explanation

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive personnel (AP)? (Select all that apply.)

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

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.)

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)