A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality?
Sharing the client's prognosis with a member of the client's family.
Discussing the client's status with a member of the spiritual support team.
Collaborating with a nurse from another unit about the client's care.
Providing client information to another nurse at change of shift.
The Correct Answer is D
The correct answer is choice **d. Providing client information to another nurse at change of shift**.
Choice A rationale:
Sharing the client's prognosis with a family member without the client's consent violates the client's right to confidentiality. The nurse should only disclose information to family members if the client has provided permission or if it is necessary for the client's care.
Choice B rationale:
Discussing the client's status with a member of the spiritual support team may be appropriate if the client has consented to spiritual support and the nurse limits the discussion to information relevant to the spiritual care. However, disclosing the client's diagnosis or other sensitive information without the client's consent would still be a breach of confidentiality.
Choice C rationale:
Collaborating with a nurse from another unit about the client's care is appropriate if it is necessary for the client's treatment and if the discussion is limited to information relevant to the client's care. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Choice D rationale:
Providing client information to another nurse at change of shift is necessary for the continuity of the client's care and is considered an appropriate disclosure within the healthcare team. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "Complained about having incisional pain."
Choice A rationale:
Documenting a client's complaints about pain, especially incisional pain, is crucial in an electronic health record. Pain assessment and management are essential aspects of client care, and including this information helps to track the client's pain level, the effectiveness of pain interventions, and any changes in their condition over time.
Choice B rationale:
While it's important to monitor fluid intake and output, stating that the client "Voided adequate amounts through the shift" might be relevant to the client's overall condition but lacks specific information. It doesn't address the reason for the assessment, and the focus should be on the client's immediate care needs and responses.
Choice C rationale:
Noting that the client "Became short of breath when ambulating" is significant for documenting any potential signs of respiratory distress during activity. This information provides valuable insights into the client's ability to tolerate physical exertion and might indicate a need for further assessment or interventions.
Choice D rationale:
Documenting that the client "Appeared to be sleeping while in bed" might not offer significant clinical information unless there is a specific reason for noting the client's sleep patterns. Sleep is an important aspect of recovery, but this choice lacks the context needed to make it a priority entry in the documentation.
Correct Answer is B
Explanation
The correct answer is choice B: Performance of a paracentesis.
Choice A rationale:
Administration of an enema does not require informed consent in the same way that invasive procedures do. Enemas are typically considered routine nursing interventions and are not as invasive as the other options.
Choice B rationale:
This is the correct choice. A paracentesis is an invasive procedure that involves puncturing the abdominal cavity to withdraw fluid. Informed consent is required for procedures that carry potential risks, and paracentesis falls into this category due to the risk of complications such as infection, bleeding, or organ injury.
Choice C rationale:
Insertion of an indwelling urinary catheter is a common nursing procedure that, while invasive, does not typically require informed consent. However, the nurse should still explain the procedure to the client and obtain verbal consent, but it's not the same level of formal informed consent required for more invasive procedures.
Choice D rationale:
Placement of an NG tube, although uncomfortable, is not as invasive as a paracentesis. In most cases, NG tube placement is considered a medical or nursing intervention rather than a procedure that necessitates formal informed consent.
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