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?
Tell the APS to stop the conversation.
Document the event in the client's progress notes.
Inform the client of the APs' actions.
Submit an incident report to the risk manager.
The Correct Answer is A
A. Correct. Overhearing private client information being discussed by staff members violates the client's right to privacy and confidentiality. The nurse should address the situation immediately and instruct the assistive personnel to stop the conversation.
B. Incorrect. While documenting the event in the client's progress notes may be necessary, addressing the inappropriate behavior of the assistive personnel takes precedence.
C. Incorrect. Informing the client about the conversation is not necessary and may further compromise the client's sense of privacy.
D. Incorrect. Submitting an incident report to the risk manager might be necessary, but the immediate action should be to stop the conversation and address the breach of confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: It’s normal for a 4-year-old child to ask the same questions repeatedly. This is a part of their learning process as they are trying to understand the world around them. They often ask the same questions to reassure themselves about the consistency and predictability of the world. However, this is not a priority issue compared to the other options.
Choice B rationale: While it’s important for children to have a balanced diet, including green vegetables, it’s also common for children to be picky eaters. Parents can introduce new foods gradually and make meal times fun to encourage children to eat a variety of foods. However, this is not a priority issue compared to the other options.
Choice C rationale: Bedwetting is common in children and can be a part of their development. Most children outgrow bedwetting by the time they start school. However, if the child is stressed or has a medical condition, it could lead to bedwetting. While this could be a concern, it’s not the priority issue in this scenario.
Choice D rationale: A change in behavior, such as becoming withdrawn, can be a sign of emotional distress in a child. This could be due to a variety of reasons, including changes in their environment like switching day care providers. This is the priority for the nurse to address as it could indicate that the child is having difficulty adjusting to the new day care, which could impact their emotional well-being.
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