Chest x-ray: Consolidation in the right lower lobe consistent with pneumonia Review H and P, nurse's notes, flow sheet, doctor's order, and Imaging studies.

What statements indicate the client's confusion is resolving?

Select all that apply.

Choice A reason:

Requesting that the man get up and leave disregards the client's autonomy and right to privacy. It can be seen as intrusive and disrespectful, potentially causing embarrassment and distress to the client. In a long-term care facility, residents have the right to engage in consensual relationships. By asking the man to leave, the nurse would be infringing on the client's personal rights and freedoms. This action could also damage the trust and rapport between the nurse and the client, making future interactions more difficult.

Choice B reason:

Reporting the incident to the family breaches the client's confidentiality and privacy. The client has the right to engage in consensual relationships without family interference unless there are concerns about safety or capacity. Involving the family in such personal matters without the client's consent can lead to unnecessary conflict and distress. It is important for healthcare providers to respect the client's autonomy and confidentiality, ensuring that their personal choices are honored and protected.

Choice C reason:

Exiting the room and quietly closing the door respects the client's privacy and autonomy. It acknowledges their right to intimate relationships and maintains their dignity. This action demonstrates respect for the client's personal space and choices, fostering a supportive and respectful environment. By quietly exiting, the nurse avoids causing embarrassment or discomfort, allowing the client to maintain their dignity and privacy. This approach aligns with ethical principles in healthcare, emphasizing respect for the client's autonomy and personal rights.

Choice D reason:

Asking when the nurse should return interrupts the client's private moment. It can be handled more discreetly by returning later without disturbing them. This action, while less intrusive than asking the man to leave, still fails to fully respect the client's privacy. By asking when to return, the nurse is drawing attention to the situation, which can cause embarrassment and discomfort. A more respectful approach would be to quietly exit and return at a later time, ensuring that the client's privacy is maintained.

Taking a rectal temperature requires a higher level of skill and carries a higher risk of injury compared to other methods, especially when dealing with a 2-year-old child with leukemia. Given the client's condition, it is important to minimize any potential harm or discomfort. Taking a tympanic temperature is a safer alternative that provides an accurate reading without the risk of injury.
B. Reminding the UAP to lubricate the thermometer before insertion is not appropriate because the PN should not encourage or support the UAP in performing a rectal temperature on a high-risk client. The focus should be on using a safer and less invasive method.
C. Instructing the UAP to report the results to the PN immediately is not necessary in this situation because the PN has already determined that taking a rectal temperature is not appropriate.
Instead, the PN should guide the UAP toward using the tympanic method.

D. Observing the UAP to ensure the thermometer is inserted correctly is not appropriate in this case because the PN has already determined that taking a rectal temperature is not the recommended course of action. It is more appropriate to redirect the UAP to use an alternative method.