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.

Participate in an in-service about client confidentiality.

Tell the staff members to stop their discussion.

Speak to the staff members in private about client confidentiality.

Answer and Explanation

The Correct Answer is C

a. While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b. Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d. Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

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Correct Answer is C

Explanation

When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.

The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.

A. Use written signs to assist the client with locating the bathroom. B. Limit the number of choices for the client. C. Use confrontation to manage the client's behavior. D. Provide a stimulating environment for the client.

Correct Answer is B

Explanation

It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.

Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.

Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.

Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.

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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

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