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:

Tingling of the scalp. Tingling of the scalp is not a common adverse reaction following electroconvulsive therapy (ECT) ECT primarily affects the brain and may result in memory-related side effects, but tingling of the scalp is not typically associated with this procedure.

Choice C rationale:

Voice alteration. Voice alteration is not a common adverse reaction to ECT. ECT is a procedure that involves inducing controlled seizures in the brain, and its primary effects are on cognitive and neurological function rather than the vocal cords or voice.

Choice D rationale:

Neck pain. Neck pain is not a common adverse reaction to ECT. This procedure primarily affects the brain and central nervous system, and neck pain is not typically associated with it.

Choice B rationale:

Temporary memory loss. Temporary memory loss is a well-documented and common adverse reaction to electroconvulsive therapy (ECT) ECT can affect memory consolidation, and clients may experience temporary memory gaps or difficulties recalling recent events. However, these memory deficits are usually short-term and improve over time.

A. Elevated blood pressure. B. Clammy skin. C. Fruity breath odor. D. Bounding pulse.

Correct Answer is C

Explanation

Choice A rationale:

Elevated blood pressure is not typically associated with diabetic ketoacidosis (DKA) In fact, individuals with DKA often experience low blood pressure due to dehydration.

Choice B rationale:

Clammy skin can occur in DKA due to dehydration and metabolic disturbances, but it is not a specific finding that differentiates DKA from other conditions.

Choice D rationale:

A bounding pulse is not a characteristic finding in DKA. Individuals with DKA may have a rapid pulse due to the stress on the body, but it is not typically described as bounding.

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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?