A nurse is caring for a client on a medical-surgical unit. Which of the following actions should the nurse take to maintain the client's confidentiality?
List the client's name and condition on board at the nurses' station.
Fax client information with a cover sheet.
Discuss the client's condition with a nurse on another unit.
Post client diagnosis on message board in their room.
The Correct Answer is B
Rationale
A. List the client's name and condition on board at the nurses' station: Displaying client information in a public area can be seen by unauthorized personnel or visitors, violating confidentiality. Sensitive information should never be visible to others not involved in the client’s care.
B. Fax client information with a cover sheet: Using a cover sheet when faxing ensures that client information is protected from unauthorized viewing. This method complies with privacy regulations and maintains confidentiality during necessary communication.
C. Discuss the client's condition with a nurse on another unit: Sharing client information with staff not involved in the client’s care can violate confidentiality. Discussions should be limited to team members directly responsible for the client or conducted through secure channels.
D. Post client diagnosis on message board in their room: Posting sensitive information where others might see it, including visitors or other clients, breaches confidentiality. Personal health information should only be accessible to authorized caregivers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Lethargy: Lethargy is more commonly associated with hypercalcemia, which depresses the central nervous system. In hypocalcemia, neuromuscular excitability is increased, so clients are more likely to experience irritability or paresthesia rather than lethargy.
B. Constipation: Constipation is a manifestation of hypercalcemia due to decreased smooth muscle contractility. Hypocalcemia typically increases neuromuscular excitability and does not generally cause constipation.
C. Positive Chvostek's sign: A positive Chvostek's sign indicates facial muscle twitching in response to tapping over the facial nerve and is a hallmark sign of hypocalcemia. It reflects increased neuromuscular excitability due to low calcium levels and is commonly used in assessment.
D. Muscle flaccidity: Muscle flaccidity occurs with hypercalcemia or decreased neuromuscular activity. In hypocalcemia, muscles are more likely to exhibit tetany, spasms, or cramping due to heightened excitability, rather than flaccidity.
Correct Answer is A
Explanation
Rationale
A. Keep the head of the client's bed at 30° or less: Elevating the head of the bed to 30° or less reduces pressure on the sacrum and heels, which are common sites for pressure injury in immobile clients. Maintaining this position helps prevent shear and friction forces that contribute to skin breakdown.
B. Bathe the client with soap and hot water: Using soap and hot water can strip natural oils from the skin, increasing dryness and the risk of breakdown. Gentle cleansing with lukewarm water and mild, pH-balanced soap is recommended to preserve skin integrity.
C. Slide the client up in bed every 2 hr: Sliding the client up in bed creates shear and friction forces on the skin, which can exacerbate pressure injuries. Repositioning should involve lifting or using a draw sheet to move the client safely without dragging the skin.
D. Massage bony prominences four times daily: Massaging bony prominences can damage underlying tissue and worsen skin breakdown. Pressure should be relieved through repositioning and support surfaces rather than direct massage of high-risk areas.
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