Nurse Z is extremely attentive to their client's emotional & spiritual needs. The nurse spends up to 45 minutes each day providing the psychosocial support. As a result, the nurse does not plan enough time to perform assessments or give medications on time. This nurse is liable for:

poor time management

neglect

fraud

an intentional tort

Answer and Explanation

The Correct Answer is A

A. Poor time management: This option is the correct answer. Poor time management occurs when a nurse fails to allocate sufficient time to complete essential nursing tasks, such as assessments and medication administration, due to excessive focus on non-priority activities, such as providing emotional and spiritual support. In this scenario, Nurse Z's inability to plan and allocate adequate time for essential nursing duties indicates poor time management skills.

B. Neglect: Neglect involves the failure to provide necessary care or attention to a client's needs, resulting in harm or potential harm. While Nurse Z's excessive focus on emotional and spiritual support may lead to neglect of other essential nursing responsibilities, the primary issue in this scenario is poor time management rather than deliberate neglect.

C. Fraud: Fraud involves intentional deception or misrepresentation for personal gain. There is no indication in the scenario that Nurse Z's actions involve deceit or manipulation for personal benefit, so fraud is not applicable in this context.

D. Intentional tort: Intentional torts involve deliberate actions that result in harm to another person. Nurse Z's failure to plan enough time for assessments and medication administration appears to stem from poor time management rather than intentional harm, so an intentional tort is not applicable in this scenario.

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Correct Answer is C

Explanation

A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.

B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.

C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.

D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.

A. Multiple lesions on dorsal aspect of feet probably due to elder abuse B. Four burned areas noted on plantar area of each foot C. Several partially healed lesions on bottom of left foot, looks like cigarette burns D. Four round, 2 cm in diameter lesions on plantar aspect of right foot

Correct Answer is D

Explanation

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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Nurse Z is extremely attentive to their client's emotional & spiritual needs. The nurse spends up to 45 minutes each day providing the psychosocial support. As a result, the nurse does not plan enough time to perform assessments or give medications on time. This nurse is liable for:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who presents with a sudden 5 lb. (2.3 kg) weight gain, bounding pulses, and a blood pressure of 174/94. These clinical findings are indicative of:

Correct Answer is C

Explanation

What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Correct Answer is D

Explanation

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