A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition.
Which of the following actions should the nurse take to maintain the client's confidentiality?

Request additional information about the caller's relationship to the client.

Provide a general update about the client's condition over the telephone.

Refer the family member to the client's provider for the update.

Encourage the family member to contact the client directly for information.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Refer the family member to the client’s provider for the update.

Choice A rationale: Requesting additional information about the caller’s relationship to the client does not ensure the caller is authorized to receive information. It could still breach confidentiality if the caller is not verified.

Choice B rationale: Providing a general update about the client’s condition over the telephone can violate confidentiality, as it is difficult to verify the caller’s identity and authorization.

Choice C rationale: Referring the family member to the client’s provider for the update is the best action to maintain confidentiality. The provider can verify the caller’s authorization and ensure that any information shared is appropriate and compliant with privacy regulations.

Choice D rationale: Encouraging the family member to contact the client directly for information is not always feasible, especially if the client is unable to communicate. It also does not address the issue of verifying the caller’s authorization to receive information.

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Correct Answer is A

Explanation

Choice A rationale:

This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.

Choice B rationale:

Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling

Choice C rationale:

Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort

Choice D rationale:

Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.

A. Tachycardia. B. Hypotension. C. Narrowed pulse pressure. D. Increasingly severe headache.

Correct Answer is D

Explanation

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.

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A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

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A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition.
Which of the following actions should the nurse take to maintain the client's confidentiality?