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 AP's actions.

Submit an incident report to the risk manager.

Answer and Explanation

The Correct Answer is A

Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.

When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.

The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.

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Correct Answer is C

Explanation

c. Physical assessment findings

Physical assessment findings are important to include in a referral for a physical therapist because they provide information about the client's current physical condition, including range of motion, strength, and any areas of pain or discomfort.

This information is essential for the physical therapist to develop an appropriate treatment plan for the client. Family medical history and medical health insurance claims may be important for overall client care, but are not directly relevant to a referral for a physical therapist.

Medications taken prior to admission may be relevant if they aﬀect the client's physical abilities or pain level, but again, physical assessment findings are more directly related to the referral for a physical therapist.

A. No sounds heard after listening for 3 to 5 min B. Sounds are soft and at a rate of 1/min C. Indicates decreased motility D. Sounds are high-pitched

Correct Answer is D

Explanation

Hyperactive bowel sounds refer to an increased intensity, frequency, and loudness of bowel sounds. They are typically described as loud, high-pitched, and occurring more frequently than normal. This can indicate increased bowel motility and may be associated with conditions such as diarrhea, gastroenteritis, or bowel obstruction.

No sounds heard after listening for 3 to 5 minutes: This describes absent or hypoactive bowel sounds, where no sounds or very few sounds are heard. It can indicate decreased or absent bowel motility and may be seen in conditions such as ileus or peritonitis.

Sounds are soft and at a rate of 1/min: This describes normal or hypoactive bowel sounds, where the sounds are relatively quiet and occur at a slower rate (usually 5-34 sounds per minute). It may be observed in situations such as during sleep, after eating, or in certain conditions like constipation or paralytic ileus.

Indicates decreased motility: This is an inaccurate statement for hyperactive bowel sounds.

Hyperactive bowel sounds actually indicate increased motility, as mentioned earlier. Decreased motility would be associated with hypoactive or absent bowel sounds.

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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

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is C

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Correct Answer is D

Explanation

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