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Justin Bieber feat Taylor Swift BABY REMIX. This is a non-invasive procedure and does not require preparation other than client education. A client is admitted with infective endocarditis IE. Which finding would alert the nurse to a complication of this condition? A dyspnea B heart murmur C macular rash D Hemorrhage B: heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets.
These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs, and obstruct blood flow. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from A a tissue bank. Autografts are done with tissue transplanted from the client''s own skin.
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A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A Diffuse expiratory wheezing B Loose, productive cough C No relief from inhalant D Fever and chills A: Diffuse expiratory wheezing. In asthma, the airways are narrowed, creating difficulty getting air in. A wheezing sound results.
A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?
A Maintaining proper body alignment B Frequent neurovascular assessments of the affected leg C Inspection of pin sites for evidence of drainage or inflammation D Applying an over-bed trapeze to assist the client with movement in bed B: Frequent neurovascular assessments of the affected leg.
The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. The nurse is assigned to care for a client who had a myocardial infarction MI 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?
A Daily needs and concerns B The overview cardiac rehabilitation C Medication and diet guideline D Activity and rest guidelines A: Daily needs and concerns. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night.
A allergies B scabies C regression D pinworms 3D: pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span.
Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei. The presence of the mite leads to intense itching in the area of its burrows.
The nurse is caring for a newborn with tracheoesophageal fistula.
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Which nursing diagnosis is a priority? A Risk for dehydration B Ineffective airway clearance C Altered nutrition D Risk for injury B: Ineffective airway clearance. The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed.
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best? A Fish sticks, french fries, banana, cookies, milk B Ground beef patty, lima beans, wheat roll, raisins, milk C Chicken nuggets, macaroni, peas, cantaloupe, milk D Peanut butter and jelly sandwich, apple slices, milk B: Ground beef patty, lima beans, wheat roll, raisins, milk.
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Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice: It is high in iron and is appropriate for a toddler. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? A Metabolic acidosis B Metabolic alkalosis C Some increase in the serum hemoglobin D A little decrease in the serum potassium B: Metabolic alkalosis.
Vomiting causes loss of acid from the stomach.
Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse.
Options C and D are correct answers but not the best answers since they are too general. A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days.
Nutritional counseling by the nurse should include which statement? A Place the child on clear liquids and gelatin for 24 hours B Continue with the regular diet and include oral rehydration fluids C Give bananas, apples, rice and toast as tolerated D Place NPO for 24 hours, then rehydrate with milk and water B: Continue with the regular diet and include oral rehydration fluids.
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate. The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A formula or breast milk B broth and tea C rice cereal and apple juice D gelatin and ginger ale A: formula or breast milk.
The usual diet for a young infant should be followed. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A call for emergency transport to the hospital B immobilize the limb and joints above and below the injury C assess the child and the extent of the injury D apply cold compresses to the injured area C: assess the child and the extent of the injury.
When applying the nursing process, assessment is the first step in providing care. The "5 Ps" of vascular impairment can be used as a guide pain, pulse, pallor, paresthesia, paralysis. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet.
What should be emphasized as the nurse teaches about infant nutrition? A Solid foods should be introduced at months B Whole milk is difficult for a young infant to digest C Fluoridated tap water should be used to dilute milk D Supplemental apple juice can be used between feedings B: Whole milk is difficult for a young infant to digest. Cow''s milk is not given to infants younger than 1 year because the tough, hard curd is difficult to digest. In addition, it contains little iron and creates a high renal solute load.
The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A Solid foods are introduced one at a time beginning with cereal B Finely ground meat should be started early to provide iron C Egg white is added early to increase protein intake D Solid foods should be mixed with formula in a bottle A: Solid foods are introduced one at a time beginning with cereal.
Solid foods should be added one at a time between months. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food. The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority? A Limit fluids B Client controlled analgesia C Cold compresses to elbow D Passive range of motion exercise B: Client controlled analgesia.
Management of a sickle cell crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first? A Perform traumatic procedures B Use minimal physical contact C Proceed from head to toe D Explain the exam in detail B: Use minimal physical contact.
source: cienciapaladina.com girl doing handspring. Gymnast girl standing on hands while home training. Flexible girl bending ATI Mental Health Proctored Exam Questions & Answers ATI Mental Health Proctored A charge nurse is discussing mental status exams with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? Select all that apply A. To assess cognitive ability I should ask the client to count backward by sevens 06/07/ ClubSeventeen Layla Price "Flexible Babe Home Alone". Photos. 10 Megapixels, xpx. Size: 50 MB. Download from cienciapaladina.com Disclaimer: This site is only for demonstration purposes. All images are copyrighted to their respective owners. All content cited is derived from their respective sources
The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action. What finding signifies that children have attained the stage of concrete operations Piaget? A Explores the environment with the use of sight and movement B Thinks in mental images or word pictures C Makes the moral judgment that "stealing is wrong" D Reasons that homework is time-consuming yet necessary C: Makes the moral judgment that "stealing is wrong".
The stage of concrete operations is depicted by logical thinking and moral judgments. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A "Folic acid should be taken before and after conception. There is evidence that increased amounts of folic acid prevents neural tube defects.
The provider orders Lanoxin digoxin 0. Which of these foods would the nurse reinforce for the client to eat at least daily?
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A Spaghetti B Watermelon C Chicken D Tomatoes B: Watermelon. Watermelon is high in potassium and will replace potassium lost by the diuretic. The other foods are not high in potassium. While teaching the family of a child who will take phenytoin Dilantin regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?
A Maintain good oral hygiene and dental care B Omit medication if the child is seizure free C Administer acetaminophen to promote sleep D Serve a diet that is high in iron A: Maintain good oral hygiene and dental care.
Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized. The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child.
Which statement by the parent indicates understanding of appropriate precautions to take with the children?
Small children and infants are not to be left unsupervised. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? A "The injury is expected to heal quickly because of thin periosteum. An epiphyseal growth plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg.
A "They will be back right after supper. Preschoolers interpret time with their own frame of reference. Thus, it is best to explain time in relationship to a known, common event. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A once each day B 3 times daily after meals C with each meal or snack D each time carbohydrates are eaten C: Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten.
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
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A Use ready-to-feed commercial infant formula B Boil the tap water for 10 minutes prior to preparing the formula C Let tap water run for 2 minutes before adding to concentrate D Buy bottled water labeled "lead free" to mix the formula C: Let tap water run for 2 minutes before adding to concentrate.
Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
A Scratching the head more than usual B Flakes evident on a student's shoulders C Oval pattern occipital hair loss D Whitish oval specks sticking to the hair D: Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs nits firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor? A Household pets B New furniture C Lead based paint D Plants such as cactus A: Household pets. Animal dander is a very common allergen affecting persons with asthma.
Other triggers may include pollens, carpeting and household dust. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations.
She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated with the findings the infant is displaying?
Influenza A: DTaP. The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. A "I think you or your partner needs to stay with the child while in the hospital. In toddlers, ages 1 to 3, separation anxiety is at its peak A couple experienced the loss of a 7 month-old fetus.
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In planning for discharge, what should the nurse emphasize? A To discuss feelings with each other and use support persons B To focus on the other healthy children and move through the loss C To seek causes for the fetal death and come to some safe conclusion D To plan for another pregnancy within 2 years and maintain physical health A: To discuss feelings with each other and use support persons. To communicate in a therapeutic manner, the nurse''s goal is to help the couple begin the grief process by suggesting they talk to each other, seek family, friends and support groups to listen to their feelings.
The nurse is performing a pre-kindergarten physical on a 5 year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse?
A vastus intermedius B gluteus maximus C vastus lateralis D dorsogluteaI C: vastus lateralis. Vastus lateralis, a large and well developed muscle, is the preferred site, since it is removed from major nerves and blood vessels.
A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate A Non stress test B Abdominal ultrasound C Pelvic exam D X-ray of abdomen B: Abdominal ultrasound.
The standard for diagnosis of placenta previa, which is suggested in the client''s history of painless bleeding, is abdominal ultrasound. A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states "This is not my baby, and I do not want it. Her eyes are just like yours.
The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of At AM the child's parent reports that the child "feels very warm" to touch. The first action by the nurse should be to A reassure the parent that this is normal B offer the child cold oral fluids C reassess the child's temperature D administer the prescribed acetaminophen C: reassess the child''s temperature.
A child''s temperature may have rapid fluctuations.
The nurse should listen to and show respect for what parents say. Parental caretakers are often quite sensitive to variations in their children''s condition that may not be immediately evident to others. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is critical for the nurse to include in the plan of care? A hourly urine output B white blood count C blood glucose every 4 hours D temperature every 2 hours A: hourly urine output.
Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion.
Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy.
Close observation of hourly urinary output is necessary for early detection of this condition. A client is admitted to the rehabilitation unit following a cerebral vascular accident CVA and mild dysphagia. The most appropriate intervention for this client is to A position client in upright position while eating B place client on a clear liquid diet C tilt head back to facilitate swallowing reflex D offer finger foods such as crackers or pretzels A: position client in upright position while eating.
An upright position facilitates proper chewing and swallowing. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing.
The nurse expects that the first action in the sequence of care for this client will be to A Maintain the airway B Administer epinephrine as ordered C Monitor for hypotension with shock D Administer diphenhydramine as ordered B: Administer epinephrine as ordered. All the answers are correct given the circumstances, but the priority is to administer the epinephrine, then maintain the airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normotensive, administering the epinephrine is first, and applying the oxygen, and watching for hypotension and shock, are later responses.
The prevention of a severe crisis is maintained by using diphenhydramine. The nurse instructs the client taking dexamethasone Decadron to take it with food or milk.
The physiological basis for this instruction is that the medication A retards pepsin production B stimulates hydrochloric acid production C slows stomach emptying time D decreases production of hydrochloric acid B: stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause gastrointestinal ulcers. A client receiving chlorpromazine HCL Thorazine is in psychiatric home care.
During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? A Dystonia B Akathisia C Brady dyskinesia D Tardive dyskinesia D: Tardive dyskinesia.
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly catching" tongue movements. These findings are often described as Parkinsonian. Which of the following findings contraindicate the use of haloperidol Haldol and warrant withholding the dose? A Drowsiness, lethargy, and inactivity B Dry mouth, nasal congestion, and blurred vision C Rash, blood dyscrasias, severe depression D Hyperglycemia, weight gain, and edema 8C: Rash, blood dyscrasias, severe depression.
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history of severe depression is a contraindication to the use of neuroleptics.
The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir Zovirax for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A Complete the entire course of the medication for an effective cure B Begin treatment with acyclovir at the onset of symptoms of recurrence C Stop treatment if she thinks she may be pregnant to prevent birth defects D Continue to take prophylactic doses for at least 5 years after the diagnosis B: Begin treatment with acyclovir at the onset of symptoms of recurrence.
When the client is aware of early symptoms, such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease; they simply decrease the level of symptoms.
A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? A Hypothermia B Edema C Dyspnea D Epistaxis D: Epistaxis. A large dose of aspirin inhibits prothrombin formation and lowers platelet levels.
With an overdose, clotting time is prolonged. An 80 year-old client on digitalis Lanoxin reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A Potassium levels B Blood pH C Magnesium levels D Blood urea nitrogen A: Potassium levels. The most common cause of digitalis toxicity is a low potassium level. Clients must be taught that it is important to have adequate potassium intake especially if taking diuretics that enhance the loss of potassium while they are taking digitalis.
A 42 year-old male client refuses to take propranolol hydrochloride Inderal as prescribed. Which client statement from the assessment data is likely to explain his noncompliance? A "I have problems with diarrhea. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred.
The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time?
A Risk for fluid volume deficit related to morphine overdose B Decreased gastrointestinal mobility related to mucosal irritation C Ineffective breathing patterns related to central nervous system depression D Altered nutrition related to inability to control nausea and vomiting C: Ineffective breathing patterns related to central nervous system depression. Respiratory depression is a life-threatening risk in this overdose. Lactulose Chronulac has been prescribed for a client with advanced liver disease.
Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A An increase in appetite B A decrease in fluid retention C A decrease in lethargy D A reduction in jaundice C: A decrease in lethargy. Lactulose produces an acid environment in the bowel and traps ammonia in the gut; the laxative effect then aids in removing the ammonia from the body.
This decreases the effects of hepatic encephalopathy, including lethargy and confusion. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A Donating blood B Using public bathrooms C Ucienciapaladina.comotected sex D Touching a person with AIDS C: Ucienciapaladina.comotected sex. Because HIV is spread through exposure to bodily fluids, ucienciapaladina.comotected intercourse and shared drug paraphernalia remain the highest risks for infection.
While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to A ask the client what she is feeling B assess the client for auditory hallucination C recognize the behavior as a side effect of medication D re-focus the discussion on a less anxiety provoking topic A: ask the client what she is feeling.
The initial step in anxiety intervention is observing, identifying, and assessing anxiety. The nurse should seek client validation of the accuracy of nursing assessments and avoid drawing conclusions based on limited data. In the situation above, the client may simply need to use the restroom but be reluctant to communicate her need! A young adult seeks treatment in an outpatient mental health center.
The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war.
What is the most therapeutic approach by the nurse? The client''s comments demonstrate grandiose ideas. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate?
A Increased serum glucose B Decreased albumin C Decreased potassium D Increased sodium retention C: Decreased potassium.
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In bulimia, loss of electrolytes can occur in addition to other findings of starvation and dehydration. A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?
A "When you have the impulse to stop in a bar, contact a sober friend and talk with him. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A Offer the client frequent opportunities to interact with 1 person B Provide the client with frequent opportunities to interact with other clients C Assist the client to analyze the meaning of the withdrawn behavior D Discuss with the client the focus that other clients have similar problems A: Offer the client frequent opportunities to interact with 1 person.
The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships. An important goal in the development of a therapeutic inpatient milieu is to A provide a businesslike atmosphere where clients can work on individual goals B provide a group forum in which clients decide on unit rules, regulations, and policies C provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions D discourage expressions of anger because they can be disruptive to other clients C: provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions.
A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. A client with paranoid delusions stares at the nurse over a period of several days. The nurse recognizes the underlying emotion with a matter of fact attitude, but avoids telling the clients how they feel. A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks.
A Gently remind her that she is no longer on stage B Directly assist client to her room for appropriate apparel C Quietly point out to her the dress of other clients on the unit D Tactfully explain appropriate clothing for the hospital B: Directly assist client to her room for appropriate apparel. It assists the client to maintain self-esteem while modifying behavior. When teaching suicide prevention to the parents of a 15 year-old who recently attempted suicide, the nurse describes the following behavioral cue as indicating a need for intervention.
A Angry outbursts at significant others B Fear of being left alone C Giving away valued personal items D Experiencing the loss of a boyfriend C: Giving away valued personal items.
Eighty percent of all potential suicide victims give some type of indication that selfdestructiveness should be addressed. These clues might lead one to suspect that a client is having suicidal thoughts or is developing a plan. Which statement made by a client indicates to the nurse that the client may have a thought disorder?
Wait until my partner hears about this. What time is it?
Have you seen them? It's my daughter who has the problem. A neologism is a new word self invented by a person and not readily understood by another. Using neologisms is often associated with a thought disorder.
In a psychiatric setting, the nurse limits touch or contact used with clients to handshaking because A some clients misconstrue hugs as an invitation to sexual advances B handshaking keeps the gesture on a professional level C refusal to touch a client denotes lack of concern D inappropriate touch often results in charges of assault and battery A: some clients misconstrue hugs as an invitation to sexual advances.