A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?

Document the event in the client's progress notes.

Submit an incident report to the risk manager.

Inform the client of the APs' actions.

Tell the APs to stop the conversation.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Here are some possible answers: Response to other clients: This finding could indicate that the client’s condition has improved if they are more cooperative and respectful of others, or that it has declined if they are more hostile and paranoid of others. Sleep patterns: This finding could indicate that the client’s condition has improved if they are sleeping more regularly and peacefully, or that it has declined if they are sleeping less or having nightmares.

Hygiene patterns: This finding could indicate that the client’s condition has improved if they are taking care of their personal hygiene and appearance, or that it has declined if they are neglecting or refusing to do so. Interaction with the nurse: This finding could indicate that the client’s condition has improved if they are more trusting and communicative with the nurse, or that it has declined if they are more suspicious and withdrawn from the nurse.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

The nurse is assisting in the care of the client who is on the behavioral health unit. Exhibits Select words from the choices below to fill in each blank in the following sentence (Separate using commas). The nurse should plan to dropdownand dropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

Explanation

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?