A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

Criminal assault and battery.

Negligent acts of omission.

Abandonment of the victim.

Good Samaritan immunity.

Answer and Explanation

The Correct Answer is D

A. Criminal assault and battery:

Criminal assault and battery involve intentionally causing harm to another person without their consent. In this scenario, the nurse's actions were aimed at providing aid and ensuring the victim's safety. There is no indication of any intentional harm or violence toward the victim.

B. Negligent acts of omission:

Negligent acts of omission occur when a healthcare provider fails to act in a manner consistent with the standard of care, resulting in harm to another person. In this scenario, the nurse took certain actions to assist the victim, such as turning off the engine key and assessing the victim's condition. There is no indication of negligent omission as the nurse took appropriate actions given the circumstances.

C. Abandonment of the victim:

This applies if a healthcare professional leaves a patient in need of care without ensuring appropriate transfer of care. In this scenario, the nurse handed over the situation to EMS before leaving.

D. Good Samaritan immunity:

Good Samaritan laws protect individuals, including nurses, who voluntarily provide assistance in emergency situations from legal liability, as long as their actions are within the scope of their knowledge and training and are performed in good faith. The nurse stopped to help, provided care, and then reported to EMS personnel before leaving, which is consistent with the protection offered by Good Samaritan laws.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Places food on the unaffected side of the mouth:

This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.

B. Raises the head of the bed to 60 degrees:

Clients at risk for aspiration-especially after a CVA (stroke)-should have the head of the bed elevated to at least90 degrees during feeding.60 degrees is insufficient to fully protect the airway and reduce the risk of aspiration.

C. Positions the head with the chin tilted slightly downward:

Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.

D. Allows 30 minutes of rest before feeding:

Resting reduces fatigue, which can improve swallowing safety and coordination.

A. Administer PRN oral pain medication. B. Review the pain medications prescribed. C. Ask the client what is causing the grimacing. D. Monitor the client's nonverbal behavior.

Correct Answer is C

Explanation

A. Administer PRN oral pain medication:

Administering pain medication without further assessment may not be appropriate, as the client's pain needs must be fully evaluated before intervening with medication. Additionally, pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

B. Review the pain medications prescribed:

While it's important to review the client's pain medications, particularly if the client is exhibiting signs of uncontrolled pain, this intervention should be secondary to further assessment of the client's current pain status.

C. Ask the client what is causing the grimacing:

Asking the client directly about the cause of their grimacing can help clarify their discomfort and provide insight into whether their pain response is being underreported. This approach helps bridge the gap between nonverbal cues and verbal reports.

D. Monitor the client's nonverbal behavior:

While monitoring nonverbal behavior is important, it does not directly address the discrepancy between the client’s grimacing and their verbal denial of pain. This action should be complemented by further assessment to understand the cause of the nonverbal signs.

E. Establish a regular time for going to bed and getting up: This intervention is not relevant to the current situation, as the client is experiencing discomfort while moving.

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Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

The nurse enters a client's room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.