A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?

Correct Answer: B

Rationale: In this scenario, option B is the correct choice because it aligns with the legal standard used to determine negligence in a situation where a client is injured while under a nurse's care. The standard of care is established by what a reasonable, prudent nurse would do in a similar situation. Therefore, the testimony of another staff nurse regarding the expected actions of a competent and careful nurse is crucial in assessing whether negligence occurred. Option A is incorrect because the opinion of an expert nurse is not the standard used in legal proceedings to determine negligence. Option C is incorrect as the opinion of the client's attorney does not establish the standard of care for nursing practice. Option D is also incorrect because the client's provider's testimony does not define the standard of care for nursing. Educationally, understanding the legal implications of nursing practice is essential for all healthcare professionals. Nurses need to be aware of the standards of care expected of them and how these standards are applied in legal situations involving patient injuries. By knowing the correct legal standard of care, nurses can ensure they practice in a manner that minimizes the risk of negligence allegations and protects both themselves and their patients.

Correct Answer: A

Rationale: In caring for a client with anorexia nervosa, the priority goal is to ensure the client attains a healthy weight greater than the 75th percentile for age and height (Option A). This goal is critical because individuals with anorexia nervosa often have dangerously low body weights that can lead to severe medical complications, including cardiac issues and organ failure. By prioritizing weight restoration, the nurse addresses the immediate physical health risks associated with anorexia nervosa. Option B, making positive statements about body image, while important for promoting self-esteem and psychological well-being, is not the priority in this case. Clients with anorexia nervosa often have distorted body image perceptions, and addressing this issue typically follows successful weight restoration. Option C, feeling in control of her behavior, and Option D, identifying changes in the family unit that promote autonomy, are important psychosocial goals in the care of clients with anorexia nervosa. However, these goals are secondary to addressing the life-threatening physical effects of malnutrition associated with the disorder. In an educational context, it is vital for nurses to understand the hierarchy of priorities in caring for clients with anorexia nervosa. By focusing on weight restoration as the priority goal, nurses can effectively address the immediate health risks and lay the foundation for addressing psychological and social aspects of the illness in the long term. This approach ensures that client safety and well-being are the primary considerations in care planning.

Correct Answer: B

Rationale: The correct answer is B) The purpose of medication reconciliation is to prevent adverse medication reactions. This answer is correct because medication reconciliation is a crucial process in healthcare aimed at ensuring that accurate and up-to-date medication information is available for the client to prevent medication errors and adverse drug reactions. By reconciling medications, healthcare providers can identify discrepancies, such as omissions, duplications, or incorrect dosages, and take appropriate actions to prevent harm to the client. Option A is incorrect because while it is true that accredited facilities are required to have protocols for medication reconciliation, this does not directly address the purpose of the process, which is to prevent adverse medication reactions. Option C is incorrect because veracity refers to truthfulness and honesty, not specifically related to medication reconciliation. Option D is incorrect because while it is important for nurses to perform medication reconciliation at key points in a client's care, this answer does not directly address the purpose of the process in preventing adverse medication reactions. In an educational context, understanding the purpose and importance of medication reconciliation is essential for nurses to provide safe and effective care to clients. By emphasizing the goal of preventing adverse medication reactions, nurses can appreciate the significance of thorough medication reconciliation practices in promoting client safety and positive health outcomes.

Correct Answer: C

Rationale: In this scenario, the correct action for the charge nurse to take is option C: talk with the clients who have reported the LPN's lack of care. This is the most appropriate course of action as it directly addresses the concerns raised by the clients, allows for clarification of the reported issues, and provides an opportunity to gather more information to assess the situation accurately. Option A, reviewing the LPN's personnel file, is incorrect as it does not address the immediate issue of client safety and care. Option B, discussing the LPN's behavior with other nurses, may lead to gossip or speculation without concrete evidence of the reported lack of care. Option D, reassigning client care to assistive personnel, does not address the underlying problem and may compromise continuity of care for the clients. Educationally, this scenario highlights the importance of effective communication, active listening, and addressing client concerns promptly in ensuring client safety and quality care. It also emphasizes the role of the charge nurse in advocating for clients and supporting staff members in delivering optimal care.

Correct Answer: B

Rationale: In this scenario, the nurse should prioritize assessing the infant with pertussis who is receiving oxygen via nasal cannula. The correct answer is B because respiratory distress in infants with pertussis can deteriorate rapidly, necessitating immediate intervention. Oxygen therapy is crucial for maintaining adequate oxygenation in these patients. Option A is incorrect because while monitoring blood glucose in a child with diabetes is important, it is not as time-sensitive as managing respiratory distress. Option C is incorrect because although providing discharge instructions for an adolescent in sickle cell crisis is essential, it is not as urgent as assessing and managing the respiratory status of a child with pertussis. Option D is incorrect because although feeding a toddler with both arms in casts requires attention, it is not as critical as addressing the respiratory needs of a child with pertussis. Educationally, this scenario emphasizes the importance of prioritizing care based on the acuity of the patient's condition. Nurses must recognize and respond promptly to signs of respiratory distress in pediatric patients, as respiratory compromise can quickly escalate in this population. This question highlights the significance of triaging care to ensure the safety and well-being of patients in a clinical setting.