A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

Ask the client to state their room number.

Have the client state their phone number.

Request an assistive personnel to identify the client.

Review the client's photograph in the medical record.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Asking the client to state their room number is incorrect. A client with advanced dementia might not reliably remember or be able to state their room number, so this might not be a reliable method for identification.

Choice B Reason:

Having the client state their phone number is incorrect. Similar to the room number, relying on the client to state their phone number might not be feasible or reliable in cases of advanced dementia.

Choice C Reason:

Requesting an assistive personnel to identify the client is incorrect. While asking another staff member might seem practical, it might not ensure accurate identification, especially if the personnel is not directly involved in the client's care or isn't familiar enough with the client's identity due to frequent rotations or duties.

Choice D Reason:

Reviewing the client's photograph in the medical record is correct. Reviewing the client's photograph in the medical record is a reliable method to confirm the client's identity, especially in cases where the client might have difficulty providing other personal information due to advanced dementia.

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Correct Answer is C

Explanation

Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.

Choice B Reason:

Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.

Choice C Reason:

Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.

Choice D Reason:

Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.

A. "I cannot confirm or deny that we have a client by that name." B. "I will tell him you called." C. "The client's condition is stable right now." D. "He is here in the hospital, but I cannot tell you anything else."

Correct Answer is A

Explanation

Choice A Reason:

"I cannot confirm or deny that we have a client by that name." is correct. Respecting patient confidentiality is crucial in healthcare. Revealing any information about a patient's condition without proper authorization or consent could breach confidentiality laws, such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Therefore, providing minimal to no information over the phone to an unidentified caller is the appropriate approach to safeguard the patient's privacy.

Choice B Reason:

"I will tell him you called." Is incorrect. This response implies that the nurse will pass along the information or the fact that the employer called, potentially breaching the patient's confidentiality by confirming the client's presence in the hospital to an unauthorized person.

Choice C Reason:

"The client's condition is stable right now." Is incorrect. Revealing any information about the patient's condition to someone who hasn't been authorized to receive such information can breach patient confidentiality. Even stating that the condition is stable discloses some level of the patient's health status without proper consent.

Choice D Reason:

"He is here in the hospital, but I cannot tell you anything else." Is incorrect. While this response acknowledges the patient's presence in the hospital, it also hints that the nurse has information about the patient. It doesn't adhere to the standard of patient confidentiality, potentially breaching the patient's privacy.

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A nurse in a long-term care facility is preparing to administer medications to a client who has advanced dementia and does not have an identification band. Which of the following actions should the nurse take to verify the client's identity?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include? Train the bladder by voiding every 5 hr.

Correct Answer is C

Explanation

A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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