A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

"Do you understand HIPAA regulations?"

"This discussion is only appropriate in a private area."

"Please stop this discussion."

"Did you know you can be liable if you breach confidentiality?"

Answer and Explanation

The Correct Answer is C

A. While understanding HIPAA regulations is important, addressing the immediate inappropriate behavior takes precedence.

B. While directing the conversation to a private area is appropriate, stopping the discussion immediately is the priority.

C. The priority is to stop the discussion immediately to prevent further breach of confidentiality.

D. While informing about potential liability for breaching confidentiality is important, addressing the immediate behavior is the priority.

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Correct Answer is A

Explanation

A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.

A. Work with the client to create a flexible daily schedule. B. Gradually decrease the time allowed for ritualistic behavior. C. Offer solutions to assist in problem-solving. D. Teach the client to meditate about obsessive thoughts.

Correct Answer is B

Explanation

A. While creating a flexible daily schedule may be helpful, it does not directly address the core symptoms of OCD.

B. Gradually decreasing the time allowed for ritualistic behavior is a common technique used in exposure and response prevention therapy, which is an evidence-based treatment for OCD.

C. Offering solutions for problem-solving may be helpful in general, but it may not directly address the specific symptoms of OCD.

D. While meditation can be beneficial for managing stress and anxiety, it may not specifically address the compulsive thoughts and behaviors characteristic of OCD.

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A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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