A nurse is reviewing the medical record of a client.

Exhibits

Click to highlight below the findings that require immediate follow-up.

Body system/Findings

 Neurological- Alert and oriented to person, place, and time; deep tendon reflexes 4+

 Musculoskeletal - Generalized weakness with equal bilateral muscle strength and mild leg cramping 

 Respiratory- Lungs clear

 Cardiovascular- Heart rate irregular: Heart rate 95/min

 Gastrointestinal- Bowel sounds hyperactive x 4 quadrants 

Rationale:

A. Providing the client with three large meals each day may be overwhelming and may not promote an increase in food intake.

B. Limiting snacks between meals may not promote an increase in food intake and may contribute to malnutrition.

C. Providing the client with finger foods for meals is a practical approach that can promote an increase in food intake and reduce the risk of malnutrition.

D. Restricting visitors during meals may not promote an increase in food intake and may contribute to social isolation.

Rationale:

A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.

B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.

C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.

D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.