A woman in labor is receiving an antibiotic. She suddenly complains of trouble breathing, weakness and nausea. The nurse should recognize that these signs are usually indicative of impending:

Correct Answer: C

Rationale: Sudden breathing difficulty, weakness, and nausea during antibiotic administration suggest a severe allergic reaction, known as anaphylaxis. This life-threatening condition involves systemic histamine release, causing airway constriction, hypotension, and gastrointestinal distress. Pulmonary egophony relates to lung sound changes, not systemic symptoms. Amniotic fluid embolism presents with cardiovascular collapse and bleeding, not primarily nausea. Bronchospasm is airway narrowing but lacks the broader symptoms here. Immediate recognition of anaphylaxis prompts epinephrine administration and airway support, critical for maternal and fetal survival in labor.

Correct Answer: D

Rationale: False imprisonment, an intentional tort, involves deliberately restricting someone's freedom, like restraining a competent patient against their will. Malpractice and negligence are unintentional torts, stemming from carelessness or failure to meet standards, not intent. Breach of duty is a negligence component, not a standalone tort. In nursing, intentional torts require purposeful action, and false imprisonment risks legal liability, emphasizing patient rights and consent in care delivery.

Correct Answer: C

Rationale: Extracellular fluid loss (e.g., dehydration) reduces blood volume, causing a rapid, thready pulse as the heart compensates for hypovolemia. Distended jugular veins suggest fluid overload, not loss. Elevated hematocrit reflects hemoconcentration, but pulse is a more immediate sign. Increased sodium occurs with water loss, not always fluid volume. Nurses monitor pulse to detect early shock, guiding fluid replacement to restore circulation and prevent organ damage.

Correct Answer: D

Rationale: End-stage renal disease impairs potassium excretion, causing hyperkalemia as kidneys fail to filter excess. Crohn's affects absorption, Cushing's alters cortisol, and heart failure impacts circulation not potassium directly. Nurses monitor levels in renal patients, adjusting diet or dialysis to prevent arrhythmias or muscle issues from high potassium, a common complication.

Correct Answer: A

Rationale: Battery is the intentional, unconsented physical contact, like striking a patient, a civil tort with legal repercussions. Negligence is unintentional harm, tort is a broader category, and crime involves criminal law. Nurses avoid battery by obtaining consent, respecting autonomy, as violations breach ethical and legal standards, risking lawsuits or discipline.