A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?

"You have the right to decide who receives information."

"Your partner can be a great source of support for you at this time."

"Is there a reason you don't want your partner to know about your procedure?"

"The provider will be tactful when talking to your partner."

Answer and Explanation

The Correct Answer is A

Rationale:

A. "You have the right to decide who receives information.": Clients have the legal and ethical right to confidentiality regarding their medical care under HIPAA and patient privacy regulations. Respecting the client’s decision about who can receive health information reinforces autonomy and ensures that the nurse supports the client’s rights in healthcare decision-making.

B. "Your partner can be a great source of support for you at this time.": While acknowledging the potential benefits of support is empathetic, this statement does not address the client’s request for privacy. It may inadvertently pressure the client to share information, which could violate confidentiality and autonomy.

C. "Is there a reason you don't want your partner to know about your procedure?": Asking for justification may make the client feel challenged or judged. The client is not required to explain their choice, and pressing for reasons can undermine trust and respect for their privacy.

D. "The provider will be tactful when talking to your partner.": This statement assumes the provider will communicate with the partner and disregards the client’s expressed wishes. It could lead to disclosure against the client’s consent, violating confidentiality and patient rights.

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Correct Answer is C

Explanation

Rationale:

A. Keep the foot in plantar flexion: Maintaining the foot in plantar flexion increases the risk of developing foot drop by shortening the dorsiflexor muscles. This position does not support proper alignment or prevent contractures, making it counterproductive for prevention.

B. Elevate the client's feet on pillows: Elevating the feet may help reduce edema but does not prevent foot drop. It does not maintain proper dorsiflexion or support the ankle in a neutral position, so it is not effective for contracture prevention.

C. Brace the foot with an ankle-foot orthotic: An ankle-foot orthotic maintains the foot in a neutral position, preventing plantar flexion contractures and promoting proper alignment of the ankle. This intervention is highly effective for preventing foot drop in immobile clients by keeping the muscles and tendons stretched appropriately.

D. Perform passive range of motion of the ankle twice per day: Passive range of motion helps maintain joint mobility and circulation but alone may be insufficient to prevent foot drop. Consistent bracing or positioning is necessary to maintain neutral alignment when the client is not actively moving the ankle.

A. History of severe menorrhagia B. Desire to become pregnant in 1 to 2 years C. Takes antiretroviral therapy for HIV D. Report of unprotected sex in the past 24 hr

Correct Answer is A

Explanation

Rationale:

A. History of severe menorrhagia: A copper IUD can increase menstrual bleeding and cramping. Clients with a history of severe menorrhagia are at higher risk for exacerbated bleeding and anemia, making this a contraindication to IUD insertion. Alternative contraceptive methods should be considered for these clients.

B. Desire to become pregnant in 1 to 2 years: While the client’s future fertility plans may influence contraceptive choice, it is not a medical contraindication. The IUD can be removed at any time, allowing fertility to return quickly, so this does not preclude insertion.

C. Takes antiretroviral therapy for HIV: HIV infection or antiretroviral therapy is not a contraindication to IUD use. Clients with HIV can safely use intrauterine contraception, provided there are no active pelvic infections.

D. Report of unprotected sex in the past 24 hr: Recent unprotected intercourse is not a contraindication, but the nurse should assess the risk of pregnancy and consider emergency contraception if appropriate. It does not medically prevent IUD insertion.

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A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

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