A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?

Report the incident to the charge nurse.

Tell the staff members to stop their discussion.

Participate in an in-service about client confidentiality.

Speak to the staff members in private about client confidentiality.

Answer and Explanation

The Correct Answer is B

A. Reporting the incident to the charge nurse is incorrect as the first step. While this action may be necessary if the issue continues, the immediate step should be to intervene directly to stop the conversation and prevent further breach of confidentiality.

B. Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client’s medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client’s privacy is respected.

C. Participating in an in-service about client confidentiality is incorrect as the first step. While in-service education on client confidentiality is important, it is not an immediate action to address a current breach of confidentiality.

D. Speaking to the staff members in private about client confidentiality is incorrect. While private conversation is important to address the issue further, the first action is to stop the conversation immediately to prevent any further privacy violations.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Keep track of how long it takes to complete certain tasks is correct. Tracking the time it takes to complete tasks can help the nurse identify areas for improvement and prioritize tasks accordingly.

B. Delegate collection of vital signs to the assistive personnel on the team is correct. Delegating tasks such as vital sign monitoring to assistive personnel allows the nurse to focus on higher-level clinical duties and improves time management.

C. Make a priority to-do list at the beginning of the shift is correct. Creating a to-do list helps the nurse organize tasks based on urgency, improving overall time management and ensuring critical tasks are addressed.

D. Plan a time at the end of the shift to document nursing interventions is incorrect. Documentation should be done throughout the shift as interventions are performed, not solely at the end. Delaying documentation can lead to errors and missed information.

E. Complete activities with one client before moving to another client is correct. Focusing on one client at a time helps ensure each task is completed thoroughly and reduces the risk of neglecting important care steps.

A. Neck is in a flexed position B. Asymmetry of gluteal folds C. Feet turn inward D. Frenulum connected to the tip of the tongue

Correct Answer is A

Explanation

A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.

B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.

C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.

D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.

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A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

Correct Answer is A

Explanation

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