A nurse is caring for a client who requests a copy of their medical records immediately. Which of the following responses should the nurse make?
"The facility is unable to release your records."
"You must submit a written request before you can receive a copy."
"What are you planning on doing with your medical record?"
"I will make a copy of your medical records right away."
The Correct Answer is B
Choice A Reason:
Stating that the facility is unable to release the records, may not be accurate. Facilities typically have processes in place for releasing medical records upon request, although they may require written authorization.
Choice B Reason:
"You must submit a written request before you can receive a copy." This statement is correct. In most healthcare facilities, patients are required to submit a written request to obtain copies of their medical records. This process ensures that proper documentation is maintained and helps protect patient confidentiality and privacy. Additionally, providing medical records without proper authorization could violate healthcare privacy laws such as HIPAA (Health Insurance Portability and Accountability Act).
Choice C Reason:
Asking about the client's intentions with the medical record, is not appropriate as it could be seen as intrusive. Patients have the right to access their medical records for various purposes, and their intentions may not be relevant to fulfilling the request.
Choice D Reason:
Agreeing to make a copy of the medical records right away, is not the correct response without proper authorization. Making copies of medical records without following established procedures could lead to legal and ethical issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Listing names of witnesses to the fall in the nurses' notes is incorrect. While it's important to document witnesses to the fall, listing their names in the nurses' notes is not the primary action related to incident reporting. Witness information is typically included in the incident report itself.
Choice B Reason:
Sending the incident report to the ethics committee is incorrect. Incident reports are typically submitted to the appropriate department within the healthcare facility responsible for managing incidents and ensuring appropriate follow-up. Sending the incident report to the ethics committee may not be necessary unless there are specific ethical concerns related to the incident.
Choice C Reason:
Includes the client's account of the fall in the incident report is correct. When a client falls, it's essential to document the incident accurately and thoroughly. Including the client's account of the fall in the incident report demonstrates an understanding of the procedure because it provides valuable information about the circumstances surrounding the fall from the client's perspective.
Choice D Reason:
Documenting in the client's record that an incident report was filed is incorrect. Documenting in the client's record that an incident report was filed is a necessary step, but it doesn't provide detailed information about the incident itself. The incident report itself should contain comprehensive details about the fall, including the client's account, witnesses, actions taken, and any resulting injuries.
Correct Answer is D
Explanation
Choice A Reason:
The client has four new medications is incorrect. While the addition of new medications may require monitoring and adjustment, it does not directly indicate a need for occupational therapy. Medication management is typically addressed by the healthcare provider or pharmacist.
Choice B Reason:
The client has extreme difficulty swallowing is incorrect. This finding suggests dysphagia, which may require intervention from a speech-language pathologist rather than an occupational therapist. Speech-language pathologists specialize in assessing and treating swallowing difficulties.
Choice C Reason:
The client is experiencing dysarthria is incorrect. Dysarthria refers to difficulty in speaking due to weakness or poor coordination of the muscles used for speech. While it may affect communication and daily activities, it is primarily addressed through speech therapy rather than occupational therapy.
Choice D Reason:
The client requires assistance getting dressed is correct. Difficulty with activities of daily living, such as dressing, bathing, and grooming, is within the scope of occupational therapy. Occupational therapists help clients regain independence in activities of daily living through interventions aimed at improving fine motor skills, coordination, and adaptive strategies. Referring the client to an occupational therapist can help address their dressing needs and promote independence in self-care activities.
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