A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
"I cannot confirm or deny that we have a client by that name."
"I will tell him you called."
"The client's condition is stable right now."
"He is here in the hospital, but I cannot tell you anything else."
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice AReason:
Exposure to secondhand smoke is incorrect. While exposure to secondhand smoke isn't healthy for anyone, it might not be a primary trigger for seizures in most cases. However, for some individuals, exposure to certain environmental toxins or irritants might exacerbate their condition, though this varies from person to person.
Choice BReason:
Decreased temperature is incorrect. While extreme temperatures (both hot and cold) can potentially trigger seizures in some individuals, decreased temperature alone might not be a common trigger compared to other factors.
Choice C Reason:
Lack of sleep is correct. Sleep deprivation can be a significant trigger for seizures in people with epilepsy or seizure disorders. Maintaining a regular sleep schedule and ensuring adequate sleep is an important aspect of managing seizures in these individuals.
Choice D Reason:
Prolonged headache is incorrect. Headaches can sometimes be a warning sign or an aura before a seizure for some individuals, but having a headache alone might not directly trigger a seizure for most people with a seizure disorder. However, there can be a relationship between headaches and certain types of seizures in specific cases.
Correct Answer is D
Explanation
In teaching parents of a preschool-age child with heart failure, the nurse should include the following information:
Choice A Reason:
Withhold digoxin if the child's pulse is greater than 100/min. While monitoring the pulse rate is important in children taking digoxin, a pulse rate greater than 100/min alone may not always indicate the need to withhold digoxin. The decision to withhold digoxin should be based on healthcare provider instructions and specific parameters provided for the child's case.
Choice B Reason:
Increase the child's oxygen flow rate until the child no longer has cyanosis. Adjusting oxygen flow rates should be done under the guidance of healthcare providers and based on prescribed protocols. Cyanosis is a serious sign indicating decreased oxygenation and should be addressed promptly by seeking medical attention rather than attempting to adjust oxygen flow rates at home.
Choice C Reason:
Weigh the child once each month. Monitoring the child's weight is important in heart failure management to track fluid retention, but weighing the child once a month may not provide sufficient monitoring. The healthcare provider might recommend more frequent weight checks to monitor fluid status accurately.
Choice D Reason:
Provide for periods of rest. Children with heart failure often have limited cardiac reserve and can easily become fatigued. Allowing the child periods of rest is essential to conserve energy and prevent excessive fatigue or exhaustion.
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