A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:

A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL. A blood glucose level of 200 mg/dL in a child with diabetes may require management but is not an immediate life-threatening situation.

Choice B Reason:

A toddler who has nephrotic syndrome and facial edema. Facial edema in a child with nephrotic syndrome requires assessment and potential intervention but might not present an immediate threat to life compared to an airway obstruction.

Choice C Reason:

A preschool-age child who has a muffled voice and no spontaneous cough. The combination of muffled voice and the absence of spontaneous cough can be indicative of an upper airway obstruction, which can be life-threatening. This requires immediate assessment and intervention to ensure the child's airway is clear and that breathing is not compromised.

Choice D Reason:

An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb). Weight loss in an adolescent with Crohn's disease is concerning but might not represent an immediate life-threatening situation compared to a potential airway obstruction.

Choice A Reason:

"I cannot confirm or deny that we have a client by that name." This response respects the patient's right to confidentiality under HIPAA (Health Insurance Portability and Accountability Act) regulations. It neither confirms nor denies the patient's presence in the hospital, preserving the patient's privacy and confidentiality.

Choice B Reason:

"I will tell him you called." This response doesn't uphold patient confidentiality. Revealing that the employer called could indirectly confirm the patient's presence in the hospital, potentially breaching confidentiality.

Choice C Reason:

"The client's condition is stable right now." Sharing any information about the patient's condition with someone who hasn't been authorized to receive it breaches patient confidentiality. Even sharing a seemingly benign statement about stability can indirectly disclose the patient's presence in the hospital.

Choice D Reason:

"He is here in the hospital, but I cannot tell you anything else. “While it refrains from divulging more information, it still confirms the patient's presence in the hospital, breaching confidentiality.