The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury.
What legal concept applies?

Breach of duty.

Criminality.

Scope of practice.

False imprisonment.

Answer and Explanation

The Correct Answer is A

This is because the nurse had a legal obligation to turn the client every two hours as ordered, and by failing to do so, they did not exercise reasonable care that could foreseeably prevent harm to the client. This is an example of negligence, which requires four elements: duty, breach, injury and causation.

Choice B is wrong because criminality refers to the violation of criminal laws, such as theft or assault, which are not applicable in this case.

Choice C is wrong because scope of practice refers to the range of activities that a health care professional is authorized to perform based on their education, training and certification.

The nurse’s failure to turn the client does not relate to their scope of practice. Choice D is wrong because false imprisonment refers to the unlawful restraint of a person’s freedom of movement, such as locking them in a room or restraining them against their will.

The nurse’s failure to turn the client does not involve any such restraint.

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Correct Answer is C

Explanation

According to Mayo Clinic, physical therapy and exercises can improve strength, flexibility and stamina for people with fibromyalgia.

Low-impact aerobics, such as swimming or biking, are recommended as they are less likely to cause muscle soreness or injury.

Choice A is wrong because antidepressant medications can help ease the pain and fatigue associated with fibromyalgia.

They are often prescribed as part of the treatment plan.

Choice B is wrong because physical manifestations of the disease do not become progressively worse despite treatment.

Fibromyalgia is a chronic condition, but it does not damage the joints, muscles or organs.

Choice D is wrong because narcotic analgesia will not be used for long-term pain control. Opioid medications can cause significant side effects and dependence and will worsen the pain over time.

They are not recommended for fibromyalgia treatment.

A. Place the patient in a side-lying position only. B. Massage bony prominences. C. Use positioning devices such as foam wedges. D. Keep the head of the bed elevated higher than 30 degrees. E. Inspect skin every shift.

Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

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The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury. What legal concept applies?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has a new diagnosis of fibromyalgia. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Correct Answer is C

Explanation

The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

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The nurse does not turn a client every two hours as ordered, and the client develops a pressure injury.
What legal concept applies?