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 D

The correct answer is Choice D.

Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.

Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.

Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.

Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.

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Correct Answer is B

Explanation

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is D

Explanation

The correct answer is choice d. Determine any physical signs of injury.

Choice A rationale:

Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.

Choice B rationale:

Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.

Choice C rationale:

Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.

Choice D rationale:

Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is B

Explanation

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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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?