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A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained.

The primary health care provider tells a client that the nurse "does not know anything.”

The nurse restrains a client at bedtime because the client gets up during the night and wanders around.

The nurse tells a client that he will be tied down if he tries to get up from the chair.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.

Choice B rationale:

While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.

Choice C rationale:

Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.

Choice D rationale:

Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.

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Correct Answer is C

Explanation

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.

A. Petechiae on the chest. B. Increased anteroposterior diameter of the chest. C. Oxygen saturation level 96%. D. Respiratory alkalosis.

Correct Answer is B

Explanation

The correct answer is choice B. Increased anteroposterior diameter of the chest.

Choice A rationale:

Petechiae on the chest (Choice A) are tiny red or purple spots that appear on the skin due to small blood vessel breakage. They are not typically associated with COPD and emphysema. Petechiae are more often related to conditions like thrombocytopenia or certain infections, where blood clotting is impaired.

Choice B rationale:

Increased anteroposterior diameter of the chest, often referred to as "barrel chest," is a characteristic finding in clients with COPD and emphysema. This occurs due to the hyperinflation of the lungs and the loss of elasticity in the lung tissues, which causes the chest to become rounded and the ribs to be positioned more horizontally.

Choice C rationale:

An oxygen saturation level of 96% (Choice C) is within the normal range for oxygen saturation. However, while it's important for clients with COPD to maintain adequate oxygen levels, this value doesn't specifically correlate with the client's symptoms of a wet cough and occasional shortness of breath.

Choice D rationale:

Respiratory alkalosis (Choice D) involves an increase in blood pH due to decreased levels of carbon dioxide (hypocapnia) caused by hyperventilation. While respiratory alkalosis can occur in clients with COPD due to compensatory hyperventilation, it is not a direct assessment finding related to the client's symptoms of a wet cough and occasional shortness of breath.

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A nurse is reviewing unintentional and intentional torts. Which of the following clinical situations would the nurse identify as an example of assault?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Correct Answer is C

Explanation

A nurse on a Medical-Surgical unit is performing an assessment on a client who has COPD with emphysema. The client reports that he has a frequent wet cough and is occasionally short-of-breath. The nurse should anticipate which of the following assessment findings for this client?

Correct Answer is B

Explanation

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