A nurse takes actions to avoid liability when caring for a client with a psychiatric disorder. Which action is not appropriate in the prevention of liability?
The nurse establishes rapport with the client in an inpatient psychiatric setting.
The nurse documents accurately and honestly in the electronic health record.
The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission.
The nurse refers to the policy of the inpatient psychiatric setting when uncertain of a standard of care.
The Correct Answer is C
The nurse refuses to care for someone who reminds her of a family member after interviewing the client upon admission. This action is not appropriate in the prevention of liability because it violates the client’s right to receive care and may be considered as discrimination or abandonment. The nurse has a duty to provide care to all clients regardless of their personal feelings or preferences.
Choice A is wrong because establishing rapport with the client in an inpatient psychiatric setting is an appropriate action to prevent liability. It helps to build trust and communication between the nurse and the client and reduces the risk of misunderstanding or conflict.
Choice B is wrong because documenting accurately and honestly in the electronic health record is an appropriate action to prevent liability. It provides evidence of the care provided, the client’s condition and response, and any incidents or complications that occurred.
Choice D is wrong because referring to the policy of the inpatient psychiatric setting when uncertain of a standard of care is an appropriate action to prevent liability. It helps the nurse to follow the best practices and guidelines for providing safe and effective care to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
My spouse will just have to put up with any new irritability. This statement indicates that the client requires further educational reinforcement about the medication because phenelzine is an antidepressant that should improve the mood and reduce irritability. The client may also need to be assessed for possible adverse effects of phenelzine, such as agitation, insomnia, or hypomania.
Choice A is wrong because it is a correct statement. Phenelzine is a monoamine oxidase inhibitor (MAOI) that can interact with foods that contain tyramine, such as cheese and caffeine, and cause a hypertensive crisis.
The client should avoid excessive amounts of these foods while taking phenelzine.
Choice C is wrong because it is also a correct statement. Phenelzine can cause orthostatic hypotension, which is a drop in blood pressure when changing positions.
The client should change positions slowly, as dizziness may occur.
Choice D is wrong because it is partially correct. Phenelzine can cause headaches, which may be a sign of a hypertensive crisis.
Correct Answer is B
Explanation
Heat application increases blood flow and reduces muscle spasms, which can help relieve pain and promote healing. However, heat should not be applied for longer than 30 minutes at a time, as it can cause tissue damage and inflammation.
Choice A is wrong because maximum benefits do not occur within the first five minutes.
It takes time for heat to penetrate the tissues and cause vasodilation.
Choice C is wrong because the heat should not be left in place for at least one hour to be effective.
This can lead to burns, increased edema, and decreased blood flow.
Choice D is wrong because heat can not be left in place for as long as 12 hours without harmful effects.
This can cause severe tissue damage, infection, and necrosis.
Normal ranges for heat application are between 104°F and 113°F (40°C and 45°C).
The temperature should be checked frequently and adjusted according to the patient’s comfort and tolerance.
The skin should also be inspected for signs of erythema, blisters, or burns.
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