A nurse is teaching staff members about the legal terminology used in child abuse.
What definition of battery should the nurse include in the teaching?
1
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Maligning a person's character while threatening to do bodily harm.
2
A legal wrong committed by one person against property of another.
Correct3
The application of force to another person without lawful justification.
4
Behaving in a way that a reasonable person with the same education would not.
Battery means touching in an offensive manner or actually injuring another person. Battery
refers to actual bodily harm rather than threats of physical or psychological harm. Battery
refers to harm against persons instead of property. Behaving in a way that a reasonable
person with the same education would not is the definition of negligence.
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3.
Which nursing interventions require a nurse to wear gloves? (Select all that
apply.)
1
Giving a back rub.
Correct2
Cleaning a newborn immediately after delivery.
Correct3
Emptying a portable wound drainage system.
4
Interviewing a client in the emergency department.
5
Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive
Personal protective equipment (PPE) should be used because the newborn is covered with
amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed
to blood and fluid that are contained in the portable wound drainage system. PPE is not
required for a back rub; there is no indication that the nurse is in contact with body
secretions. PPE is not necessary when conducting an interview because it is unlikely that the
nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining
the blood pressure of a client, even if the client is HIV positive.
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4.
A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse
motivate the client toward independence?
1
Establish long-range goals for the client.
2
Identify errors that the client can correct.
Correct3
Reinforce success in tasks accomplished.
4
Demonstrate ways to promote self-reliance.
Success is a basic motivation for learning. People receive satisfaction when a goal is
reached. Progress toward long-range goals often is not apparent readily and may be
discouraging. Constructive criticism is an important aspect of client teaching, but if it is not
tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an
important part of teaching, but it probably will not motivate the client.
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5.
A health care provider prescribes a standard walker (pick-up walker with rubber tips
on all four legs). The nurse identifies what clinical findings that indicate the client is
capable of using a standard walker?
1
Weak upper arm strength and impaired stamina
2
Weight bearing as tolerated and unilateral paralysis
3
Partial weight bearing on the affected extremity and kyphosis
Correct4
Strong upper arm strength and non–weight bearing on the affected extremity
A walker with four rubber tips on the legs requires more upper body strength than a rolling
walker. A client who is non–weight bearing on the affected extremity is able to use
a standard walker. A rolling walker is more appropriate for a client with weak upper arm
strength and impaired stamina who is less able to lift up and move a walker with four rubber
tips. A client with unilateral paralysis is not a candidate for a standard walker; the client
must be able to grip and lift the walker with both upper extremities and move the walker
forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able
to lift up and move a walker with four rubber tips.
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6.
To prevent footdrop in a client with a leg cast, the nurse should:
1
Encourage complete bed rest to promote healing of the foot.
2
Place the foot in traction.
Correct3
Support the foot with 90 degrees of flexion.
4
Place an elastic stocking on the foot to provide support.
To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior
muscles of the lower leg) in a client with a cast, the foot should be supported with 90
degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to
prevent footdrop . Applying an elastic stocking for support also will not prevent footdrop; a
firmer support is required.
Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late
in the morning, take a high-protein snack with you to eat 20 minutes before the
examination. The brain works best when it has the glucose necessary for cellular function.
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