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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Social relationship with peers: Evaluating peer relationships helps determine the client’s emotional support system, which can influence stress levels and coping during pregnancy. However, this assessment does not pose an immediate impact on the physiologic wellbeing of the mother or fetus. It becomes more relevant after ensuring that no urgent health concerns are present.
B. Plans for attending school while pregnant: Exploring educational plans is important for long-term stability and preventing adverse socioeconomic outcomes. Although valuable for overall wellbeing, it is not an immediate safety concern. Educational planning should be addressed after assessing the pregnancy for factors that directly affect maternal–fetal health.
C. Understanding of infant care: Assessing knowledge of infant care helps identify educational needs before delivery and supports better neonatal outcomes. However, this is a future-oriented consideration and does not address the adolescent’s immediate health status. It becomes appropriate once urgent physiologic needs are evaluated.
D. Current nutritional status: Adolescents already have increased nutritional requirements for their own growth, and pregnancy further elevates these demands. Poor nutrition can lead to anemia, low birth weight, preterm birth, and delayed fetal growth, making it a priority assessment. Ensuring adequate maternal nutrition directly influences fetal development and reduces preventable complications.
Correct Answer is C
Explanation
Rationale:
A. "I will expose the irradiated area of skin to the sun for no more than 30 minutes per day.": Skin that has been irradiated is highly sensitive to sunlight, and any direct exposure can increase the risk of burns and further damage. Clients should avoid sun exposure entirely on affected areas.
B. "I will apply my favorite unscented lotion to the irradiated area of skin twice each day.": Applying lotion may be appropriate if recommended by the radiation oncology team, but the client should avoid using any lotion, cream, or ointment not approved for use on irradiated skin, as some products can irritate the area.
C. "I will use my hand instead of a washcloth to wash the irradiated area of skin.": Using the hand is the safest method for cleansing irradiated skin, as washcloths can cause friction, irritation, or breakdown. Gentle washing helps protect fragile skin and prevent injury during radiation therapy.
D. "I will make sure I have sterile water to wash the irradiated area of skin.": Sterile water is not required for routine skin care of irradiated areas. Mild soap and lukewarm tap water are typically sufficient unless the provider specifies otherwise.
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