A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

In order to protect the rights of the client, the nurse should report the behavior to the supervisor.

The client is entitled to have a relationship with anyone and the nurse should ignore the behavior.

The nurse should confront the nurse and tell them the behavior must immediately stop.

Discuss this with the client and tell them they are being emotionally manipulated.

Answer and Explanation

The Correct Answer is A

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

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Correct Answer is D

Explanation

Falsely imprisoning a client involves restricting their freedom and movement against their will without proper legal authority or justification. Option D demonstrates false imprisonment because the nurse applies restraints to restrict the client's movement and then forces the medication into the client's mouth, essentially depriving the client of their right to refuse treatment.

Options A, B, and C are not examples of false imprisonment:

A. The nurse informing the client that the behavior will not be tolerated and will be addressed by the psychiatrist is a response to the client's inappropriate behavior. It does not involve restricting the client's freedom or movement.

B. The nurse throwing the medication in the trash and documenting the client's refusal is an appropriate response to the client's refusal of medication. It respects the client's right to refuse treatment.

C. The nurse pushing the client and causing them to fall to the floor, resulting in a nosebleed, is an example of physical assault and battery, not false imprisonment. It is an inappropriate and harmful action by the nurse.

A. Laws do not provide protection against abuse when the suspect(s) is/are family members. B. The client has no financial resources to hire legal representation against the client's children. C. The client is emotionally close to the children and does not want to bring them harm. D. The client cannot claim abuse if there is no evidence of physical harm.

Correct Answer is C

Explanation

In cases of elder abuse by family members, the emotional bond and dependency on the abusers can create a significant barrier for the older adult to report the abuse. The client may fear damaging the relationship with their adult children or causing harm to the family dynamics. This emotional closeness and loyalty to the family may prevent the client from disclosing the abuse and seeking help.

Option A is not correct because laws do provide protection against elder abuse, including abuse by family members. Many jurisdictions have specific laws and protective services in place to address elder abuse.

Option B is not correct because financial resources, while important, are not the primary reason why the client has not reported the abuse. The emotional bond with the abusers is a more significant factor.

Option D is not correct because abuse does not need to involve physical harm to be considered abuse. Emotional, financial, and other forms of abuse can also be harmful and should be reported and addressed.

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A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

Correct Answer is D

Explanation

An alert, oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

Correct Answer is C

Explanation

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

A young client tells the nurse that the client's spouse died 3 months ago, and the client is feeling alone and vulnerable. Which statement indicates that the client's coping skills are adequate?

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?

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

The nurse is working with another nurse in the emergency department (ED) when a client comes in stating they have been raped during a date. Which statement made by the other nurse privately requires immediate correction?

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?