A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?

Gather additional information from the caller to verify their identity.

Request that the caller contact the client's provider directly for information.

Ask the caller to contact the client directly for information.

Provide the caller with a brief update about the client's condition.

Answer and Explanation

The Correct Answer is C

A. Gather additional information from the caller to verify their identity: Even if the caller's identity is verified, HIPAA regulations prohibit disclosing a client's medical information without the client’s explicit authorization. Verifying identity alone does not grant permission to release confidential health information.

B. Request that the caller contact the client's provider directly for information: Redirecting the caller to the provider does not resolve the issue of confidentiality. Healthcare providers are also bound by HIPAA regulations and cannot release information without proper consent, regardless of who is making the request.

C. Ask the caller to contact the client directly for information: This action respects the client’s privacy and autonomy. Under HIPAA, healthcare professionals may not disclose health information without client authorization. Advising the sibling to speak directly with the client is the appropriate response to safeguard confidentiality.

D. Provide the caller with a brief update about the client's condition: Sharing any health information without the client’s express consent is a violation of HIPAA. Even a brief update constitutes a breach of confidentiality and could result in legal and professional consequences.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bear weight on the unaffected leg: In a three-point gait, the client bears weight only on the unaffected leg while advancing both crutches and the affected leg together. This gait pattern is used when one leg is non-weight-bearing or injured, ensuring safety and stability during ambulation.

B. Stand with the crutch tips against the feet: Crutch tips should be positioned about 6 inches to the side and slightly in front of the feet to provide a stable base of support. Placing crutches directly against the feet increases the risk of slipping and instability.

C. Hold the arms straight when walking: Arms should be slightly flexed at the elbows when holding crutches to absorb shock and reduce strain. Holding the arms straight can cause fatigue and reduce control during walking.

D. Keep the crutches at the level of the axillae: Crutches should be adjusted to about 1 to 2 inches (2.5 to 5 cm) below the axillae to prevent pressure on the nerves and blood vessels in the armpits, which could cause nerve damage or circulatory problems.

A. The stoma protrudes slightly from the abdomen. B. The stoma bleeds lightly when touched. C. The stoma is draining a small amount of liquid stool. D. The stoma appears dark in color.

Correct Answer is D

Explanation

A. The stoma protrudes slightly from the abdomen: A stoma that protrudes slightly (about 1–2 cm) above the skin surface is normal and indicates healthy placement. This finding does not require reporting.

B. The stoma bleeds lightly when touched: Light bleeding with gentle palpation or cleaning is common due to the stoma’s rich blood supply and is generally not concerning unless bleeding is excessive.

C. The stoma is draining a small amount of liquid stool: Liquid stool drainage is expected from a colostomy, especially in the early postoperative period. This is a normal finding that does not require reporting.

D. The stoma appears dark in color: A dark, dusky, or black stoma indicates compromised blood flow and possible ischemia or necrosis. This is a serious finding that requires immediate reporting to prevent further complications.

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A nurse in a provider's office receives a telephone call from a client's sibling requesting current information about the client's condition. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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