You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:

Correct Answer: D

Rationale: Administering a vitamin B injection to a competent client who refuses it, despite family insistence and subsequent improvement, constitutes battery. Battery is the unlawful physical contact with a person without consent, and in healthcare, consent is a fundamental right for competent adults. The client's objection overrides family wishes, and giving the injection violates autonomy, a core ethical principle. The outcome of improvement doesn't justify the action legally or ethically. Assault involves threatening harm, whereas battery is the act itself, making this the correct classification. Getting family requests in writing or focusing on the outcome doesn't negate the lack of consent. This scenario underscores the importance of respecting patient rights and the legal consequences of disregarding them, even with good intentions.

Correct Answer: A

Rationale: Individualizing a care plan is best shown by including the client's preferred times and methods, tailoring care to their unique needs and lifestyle. For instance, scheduling baths when a client feels most rested respects their routine, enhancing comfort and compliance. Writing plans manually or adapting generic ones lacks this personal touch, while matching diagnoses is standard, not individualized. This approach reflects client-centered care, ensuring interventions like wound care timing fit the individual, boosting effectiveness and satisfaction.

Correct Answer: C

Rationale: When goals aren't met during evaluation, reassessing the problem and revising the care plan is the best action. This step identifies why outcomes like reduced swelling failed, perhaps due to an outdated intervention, and adjusts accordingly. Stopping assumes evaluation ends the process, ignoring its cyclical nature. Assessing motivation or knowledge deficits might inform revisions but isn't comprehensive without reassessment. This approach ensures care evolves with the client's condition, maintaining relevance and efficacy in the nursing process.

Correct Answer: D

Rationale: A late entry with current date, time, and details of the missed procedure is best, maintaining accuracy and legality. Inserting between lines or blank spaces risks confusion, and delegating falsifies records. This method ensures transparency, critical for nursing accountability and care continuity.

Correct Answer: C

Rationale: After a fall, recording vital signs and assessment in nursing notes is most needed, providing a clinical picture post-incident like stable pulse and no fractures for care and legal purposes. Noting the report's completion or location is administrative, and explaining absence justifies but doesn't document health status. This ensures comprehensive client-focused documentation.