What should a nurse do if an order seems unclear?

Choice A rationale
Assault refers to the threat of harm or unwanted physical contact, not the actual administration of medication. In this case, the nurse’s action resulted in actual harm, which is more aligned with negligence.
Choice B rationale
Battery involves intentional physical contact without consent, such as forcibly administering medication. However, this scenario involves an error rather than intentional harm, making negligence a more appropriate term.
Choice C rationale
Negligence occurs when a healthcare provider fails to meet the standard of care, resulting in harm to the patient. Administering the wrong medication is a clear example of negligence, as it demonstrates a failure to follow proper procedures and protocols.
Choice D rationale
Invasion of privacy involves the unauthorized disclosure of personal information, which is not relevant to the scenario of administering the wrong medication.

Choice A rationale
The client properly using a cane and demonstrating a steady gait indicates that the client has good mobility and balance. This is not likely to contribute to falls. Proper use of assistive devices like canes can actually help prevent falls by providing additional support and stability.
Choice B rationale
The client takes a sleeping pill. Many sleeping pills, especially those in the benzodiazepine class, can cause drowsiness, dizziness, and impaired coordination, which significantly increase the risk of falls. These medications can affect the central nervous system, leading to decreased alertness and slower reaction times, making it more likely for the client to fall.
Choice C rationale
The client uses a raised toilet seat. Raised toilet seats are designed to make it easier for individuals to sit down and stand up from the toilet, reducing the risk of falls in the bathroom. This adaptation is generally considered a fall prevention measure rather than a risk factor.
Choice D rationale
The client wears non-skid shoes. Non-skid shoes are designed to provide better traction and reduce the likelihood of slipping. Wearing such shoes is a preventive measure against falls, not a contributing factor.