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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Correct.

Option A, reminding the client of the day and time often, aligns with this goal. Orienting the individual to time and place can help reduce confusion and disorientation commonly associated with delirium.
B. Incorrect. Offering the client several choices at mealtimes, might not directly address the issue of orientation and may potentially overwhelm the individual, exacerbating their confusion.

C. Incorrect. Discussing the client's fears and addressing their concerns is important for providing appropriate care and support.
D. Incorrect. Alternating daily caregivers may increase confusion for the client experiencing delirium. Consistency in care providers can be beneficial.

A. Posterior fontanel closed B. Anterior fontanel closed C. Rolls from back to abdomen D. Moves objects to mouth

Correct Answer is B

Explanation

A. Incorrect. The closure of the posterior fontanel by 23 months is a normal developmental milestone.
B. Correct. The anterior fontanel typically closes by 12 to 18 months of age. If it closes prematurely, it could be a sign of craniosynostosis and should be assessed by the provider.
C. Incorrect. Rolling from the back to the abdomen is a normal developmental milestone at around 46 months of age.
D. Incorrect. Moving objects to the mouth is a normal developmental behavior in infants as they explore their environment through sensory input.

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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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