A nurse is assisting in the care of a client. Nurses' Notes

2000:

The client presents to the emergency department and states, "I have been assaulted." The client was immediately placed in a treatment

room. 2015:

"The client states they were out with friends this evening and had "a little too much to drink." The client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." The client reports a history of depression. The client is a full-time college student who lives with roommates. The client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement? Select all that apply.

Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.
The other findings mentioned are typical developmental milestones for a 4-month-old infant:
1. Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
2. Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.

Tell the APS to stop the conversation.

Respecting and maintaining client confidentiality are an essential ethical and legal responsibility for healthcare professionals. When a nurse overhears APs discussing a client's information inappropriately, it is important to intervene and address the situation to protect the client's privacy. Option C, telling the APs to stop the conversation, is the appropriate initial action to take.

informing the client of the APs' actions in (option A), may not be necessary or appropriate unless the client's participation or consent is required due to the nature of the conversation or potential harm caused.

submitting an incident report to the risk manager in (option B), might be considered if the incident is significant or if the inappropriate conversation continues despite intervention. Incident reports are often used to document and address any potential breaches of client confidentiality.

documenting the event in the client's progress notes in (option D), may not be the primary action to take in this situation. While documentation of the incident may be necessary, addressing and stopping the inappropriate conversation should be the immediate priority.

In summary, when a nurse overhears APs discussing a client, the nurse should first intervene and tell the APs to stop the conversation to protect the client's confidentiality and privacy. Further actions, such as submitting an incident report or documenting the event, may be appropriate depending on the severity and ongoing nature of the situation.