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 A
Explanation
Choice A Reason:
Shrug their shoulders against mild pressure. The accessory nerve controls the movement of the trapezius and sternocleidomastoid muscles. To assess this nerve, the nurse should ask the child to shrug their shoulders against mild resistance or pressure applied by the nurse's hands on the child's shoulders. This action assesses the strength and symmetry of the trapezius muscles.
Choice B Reason:
Move their tongue in all directions. This action assesses the function of the hypoglossal nerve (cranial nerve XII), which controls tongue movement.
Choice C Reason:
Follow a light in the six cardinal positions. This action assesses the function of the extraocular muscles and cranial nerves III, IV, and VI, which control eye movements.
Choice D Reason:
Show their teeth while smiling. This action primarily assesses the facial nerve (cranial nerve VII), which controls facial expressions, including smiling and showing teeth.
Correct Answer is D
Explanation
Choice A Reason:
Stretch the perineum taut when applying the bag. Taut stretching might cause discomfort or be unnecessary for applying the collection bag and could potentially disrupt the process.
Choice B Reason:
Apply lidocaine gel to the perineum before attaching the bag. Applying lidocaine gel isn't typically necessary for routine urine collection and might not be appropriate for this procedure in an infant without specific indications for its use.
Choice C Reason:
Place a snug-fitting diaper over the drainage bag. Placing a diaper over the collection bag might interfere with the collection process, cause the bag to shift, or create unnecessary pressure on the area.
Choice D Reason:
Position the opening of the bag over the urethra and the anus. Placing the opening of the collection bag over both the urethra and the anus increases the chances of capturing urine effectively. It allows for the collection of a clean catch urine sample while minimizing the risk of contamination from the anus.
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