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

Explanation

Choice A rationale:

Gentamicin is known to have ototoxic effects and can lead to hearing loss, especially when administered via IV infusion. Monitoring for hearing changes is crucial to prevent permanent damage.

Choice B rationale:

Slurred speech is not a common adverse effect of gentamicin. It is more associated with neurological issues or medications affecting the central nervous system.

Choice C rationale:

Hyperthermia is not a typical adverse effect of gentamicin. It may be a sign of infection or another underlying condition but is not directly related to the medication.

Choice D rationale:

Hypotension is not a common adverse effect of gentamicin. It is more commonly associated with medications that affect blood pressure or underlying medical conditions.

A. "What makes you think the staff is following you?” B. "The psychiatric staff is not FBI. They are here to help you.” C. "Why do you feel the staff is the FBI?” D. "This must be very frightening for you. Let's talk more about it.”

Correct Answer is D

Explanation

Choice A rationale:

Asking, "What makes you think the staff is following you?" is a confrontational approach and may not be helpful in building rapport or addressing the client's paranoid beliefs. It can come across as dismissive and may exacerbate the client's anxiety.

Choice B rationale:

Telling the client, "The psychiatric staff is not FBI. They are here to help you," is a straightforward response but may not effectively address the client's concerns or build rapport. It does not acknowledge the client's feelings and may not be well-received.

Choice C rationale:

Asking, "Why do you feel the staff is the FBI?" is a more open-ended and therapeutic approach. It encourages the client to express their thoughts and feelings, providing an opportunity for the nurse to better understand the client's perspective.

Choice D rationale:

Saying, "This must be very frightening for you. Let's talk more about it," is the most empathetic and client-centered response. It acknowledges the client's emotions and offers support. It also opens the door for further discussion and therapeutic communication, allowing the nurse to explore the client's fears and concerns in a non-confrontational manner.

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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?

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Naxlex Comprehensive Predictor Exams

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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?