A nurse is caring for a client who repeatedly refuses meals.
The nurse overhears an assistive personnel (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
Assault.
Malpractice.
Battery.
Negligence.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is **a. Observe for bruising of the skin.**
Choice A rationale: Observing for bruising of the skin is an appropriate nursing intervention when caring for a client receiving alteplase (recombinant tissue plasminogen activator or rt-PA), a thrombolytic medication used to dissolve blood clots. Alteplase can increase the risk of bleeding, including bruising, as it works to break down the clot. Closely monitoring the client for any signs of bleeding or bruising is crucial to identify and manage potential complications.
Choice B rationale: Administering medications intramuscularly is not recommended when a client is receiving alteplase. Intramuscular injections can increase the risk of bleeding and should be avoided, as alteplase can impair the body's ability to form clots and stop bleeding.
Choice C rationale: Monitoring vital signs every 4 hours is not the appropriate frequency for a client receiving alteplase. Vital signs should be monitored more frequently, typically every 30 minutes to 1 hour, to closely observe for any changes that may indicate bleeding or other complications.
Choice D rationale: Providing a diet low in protein is not a necessary intervention for a client receiving alteplase. Alteplase works by targeting the blood clot and does not require specific dietary modifications. The focus should be on monitoring for bleeding and managing any potential complications, rather than adjusting the client's diet.
Correct Answer is B
Explanation
Choice A rationale:
Absence seizures typically last for a few seconds, not 30 to 60 seconds. This choice is incorrect because it provides inaccurate information about the duration of absence seizures.
Choice B rationale:
Absence seizures are brief episodes of staring that can be mistaken for daydreaming. It is crucial for the parent to recognize this symptom to ensure the child's safety and seek appropriate medical attention if needed.
Choice C rationale:
Absence seizures usually occur without warning or an aura. There is no specific warning sign before the onset of absence seizures, making this choice incorrect.
Choice D rationale:
Absence seizures have a sudden onset and offset without any warning signs, so they do not have a gradual onset. This information is incorrect regarding absence seizures.
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