A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

"I'm sorry but your son's medical information is none of your business.".

"The healthcare provider will share this information with you.".

"I can only give medical information to your son because he is an adult.".

"I will get these results back from the lab as soon as possible.".

Answer and Explanation

The Correct Answer is C

The best response for the nurse to provide is “I can only give medical information to your son because he is an adult.” Since the client is 19 years old and considered an adult, the nurse must respect the client’s right to privacy and confidentiality.

Choice A is not the answer because it is rude and unprofessional.

Choice B is not the answer because it does not address the issue of privacy and confidentiality.

Choice D is not the answer because it does not address the issue of privacy and confidentiality.

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Correct Answer is B

Explanation

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

A. Demonstrate the skill speaking slowly and using simple terms. B. Reassure the client that the skill is not difficult to learn. C. Reduce the stimuli in the area before continuing the teaching. D. Provide the client with step-by-step written instruction.

Correct Answer is C

Explanation

Sensory overload happens when an individual is getting more input from their senses than their brain can sort through and process 1.

Therefore, reducing the stimuli in the area can help the client’s brain to better process the information being taught.

Choice A is not the answer because demonstrating the skill speaking slowly and using simple terms does not address the issue of sensory overload 1.

Choice B is not the answer because reassuring the client that the skill is not difficult to learn does not address the issue of sensory overload 1.

Choice D is not the answer because providing step-by-step written instruction does not address the issue of sensory overload 1.

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A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is B

Explanation

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement?

Correct Answer is C

Explanation

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