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 B

Explanation

Choice A rationale:

Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.

Choice B rationale:

Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.

Choice C rationale:

Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.

Choice D rationale:

Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.

A. "I can take antacids at the same time as this medication.” B. "I will need to remain upright for 1 hour after taking the medication.” C. "I have to take this medication on an empty stomach.” D. "I should expect to have diarrhea while taking this medication.”

Correct Answer is C

Explanation

A. "I can take antacids at the same time as this medication.” This is generally incorrect. While antacids can provide quick relief, they can interfere with the absorption of pantoprazole. It's usually recommended to separate antacid use from pantoprazole by at least a couple of hours.
B. "I will need to remain upright for 1 hour after taking the medication.” This is incorrect. This is a common instruction for general GERD management, but not specifically related to taking the pantoprazole medication itself.
C. "I have to take this medication on an empty stomach.” This is generally correct. PPIs like pantoprazole work best when taken before meals, typically 30-60 minutes before breakfast. This allows the medication to be absorbed and ready to reduce acid production when you eat.
D. "I should expect to have diarrhea while taking this medication.” While diarrhea can be a side effect of pantoprazole, it's not a guaranteed or expected outcome.

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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

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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?