Choice A rationale:

Asking a patient if their neighbor can visit is not a violation of HIPAA policy as it does not involve sharing sensitive patient information.

Choice B rationale:

Using the facility computer to document patient care is appropriate and not a violation of HIPAA policy, assuming the nurse is following proper security protocols.

Choice C rationale:

Looking at a neighbor's chart to add them to a prayer list at church is a clear violation of HIPAA policy. This action breaches patient confidentiality and compromises their privacy, which is essential under HIPAA regulations.

Choice D rationale:

Failing to log off the computer charting system after documenting patient care is also a violation of HIPAA policy. This can lead to unauthorized access and potential misuse of patient information, putting patient privacy at risk.

Choice E rationale:

Discussing a patient with a coworker in a public place like an elevator violates HIPAA policy. Even though the conversation is with a colleague, it is essential to protect patient information in all circumstances to maintain confidentiality and trust.

Choice A rationale:

Avoiding assisting a restless patient to walk does not address the issue of patient confusion and the risk of falling. Restless patients might need assistance, and refusing to help them walk could lead to further complications or falls.

Choice B rationale:

Discouraging the family from staying with the patient does not promote patient safety. Family members can provide additional support and supervision, reducing the risk of falls for a confused patient.

Choice C rationale:

Moving the patient farther away from the nurses' station does not address the patient's confusion or the risk of falling. It might even increase the response time in case of an emergency.

Choice D rationale:

Asking the family about the patient's preferences for movies or music and offering these activities is an appropriate way to engage the patient without resorting to restraints. Providing stimulating and enjoyable activities can help distract and calm the patient, reducing restlessness and the risk of falls.

Choice A rationale:

The statement that abbreviations are forbidden on a medical record is not entirely accurate. While there are specific abbreviations that should be avoided, not all abbreviations are forbidden. The key is to use recognized and standard abbreviations to prevent misunderstandings.

Choice B rationale:

The statement about using abbreviations only for units of measurement is too restrictive. Abbreviations can be used for various purposes in medical charting, but it is crucial to ensure they are standard, recognized, and widely understood to maintain clarity and patient safety.

Choice C rationale:

Uncommon and unrecognized abbreviations could indeed be misunderstood, leading to misinterpretation of important information. This misunderstanding could compromise patient safety by affecting treatment decisions or medication administration. Using standardized and commonly accepted abbreviations ensures clear communication among healthcare professionals.

Choice D rationale:

Allowing the use of uncommon and unrecognized abbreviations with staff education does not guarantee patient safety. Educating staff about these abbreviations might mitigate some risks, but misunderstandings can still occur, especially in high-stress situations or when dealing with staff turnover. Standardized communication methods are essential to prevent errors.

Choice A rationale:

In the SBAR method, "S" stands for Situation. This portion of the report includes a brief and concise statement about the patient's current situation or problem. In this case, option A provides a clear and specific statement about the patient's situation, indicating that Mr. Jones is being transferred to another unit from the emergency room. The nurse would identify this statement as the "situation" portion of the SBAR report because it conveys the current status of the patient and the reason for the communication.

Choice B rationale:

Option B discusses the patient's symptoms and condition in detail, focusing on the left knee swelling, bruising, redness, and tenderness. While this information is important, it falls under the "Background" section of the SBAR report, not the "Situation" section. The "Situation" section should provide a brief overview of the patient's current status and the reason for the communication, which choice A accurately conveys.

Choice C rationale:

Option C mentions the patient's request for a specific bed location, which is relevant to the patient's preferences but does not constitute the "situation" portion of the SBAR report. This information is more appropriate for the "Recommendation" or "Request" section of the SBAR communication model.

Choice D rationale:

Option D provides information about the patient's history of left knee pain following a motor vehicle accident four days ago. While this information is important for understanding the patient's background, it does not represent the current situation or reason for the communication. Therefore, it does not fit the "situation" portion of the SBAR report.

Choice A rationale:

In the SOAP format used for medical documentation, "P" stands for Plan. The "P" portion of the note includes the healthcare provider's plan for the patient, which may involve treatments, medications, or other interventions. Option A discusses the patient's ability to walk unassisted, feelings of safety while ambulating, and plans for discharge home in 3 days. This information represents the provider's plan for the patient's care and fits the "P" portion of the SOAP note.

Choice B rationale:

Option B describes the patient's physical examination findings related to range of motion and reflexes in the lower extremities. This information falls under the "Objective" section of the SOAP note, which includes observable and measurable data. While important for the overall patient assessment, it does not represent the provider's plan for the patient's care (the "P" portion of SOAP).

Choice B rationale:

Isometric exercises involve contracting muscles without changing the length of the muscle or joint angle. In this case, squeezing the gluteal muscles tightly constitutes an isometric exercise. Isometric exercises are often used in rehabilitation settings to strengthen specific muscle groups without putting too much strain on the joints.

Choice A rationale:

Option A describes a range of motion exercise involving the wrist, which is not an isometric exercise. Isometric exercises focus on static muscle contractions, not dynamic movements like circular motions.

Choice C rationale:

Lifting a 5-pound weight to increase arm strength involves isotonic exercise, not isometric exercise. Isotonic exercises involve muscle contractions with movement and changing muscle length, unlike isometric exercises, where muscle length remains constant.

Choice D rationale:

Bending the knee up to the chest is an example of a range of motion exercise and does not constitute an isometric exercise. Range of motion exercises involve moving joints through their full extent, but isometric exercises involve static muscle contractions without joint movement.

Choice A rationale:

Calling the physician to request an antianxiety medication might address the client's anxiety, but it does not directly respond to the client's existential question about God punishing them.

Choice B rationale:

Sharing personal religious beliefs with the client can be inappropriate and may not align with the client's beliefs, potentially causing discomfort or offense.

Choice C rationale:

Sitting quietly with the client and offering caring touch demonstrates empathy, compassion, and presence. It allows the nurse to provide emotional support without imposing personal beliefs or judgments. This approach encourages the client to express their feelings and facilitates a therapeutic nurse-client relationship.

Choice D rationale:

Advising the client about a good worship center nearby does not directly address the client's existential question or provide emotional support. Additionally, the client may not be interested in religious activities at this moment.

Choice A rationale:

Telling the patient that their wife will be fine does not address the patient's concerns and may come across as dismissive. It does not encourage further communication about the patient's fears and worries.

Choice B rationale:

Dismissing the patient's concerns and instructing them to sleep does not address the underlying issue. It fails to acknowledge the patient's emotional distress and may make the patient feel unheard and unsupported.

Choice C rationale:

Offering medication without exploring the patient's concerns further does not address the root cause of the patient's anxiety. It is important to assess the patient's emotional state and concerns before resorting to medication.

Choice D rationale:

Asking the patient, "What seems to be concerning you the most?" demonstrates active listening and empathy. It encourages the patient to express their feelings and fears, allowing the nurse to provide appropriate emotional support and interventions. Open-ended questions like this facilitate therapeutic communication and help establish trust between the nurse and the patient.

Choice A rationale:

Making sure the consent is signed and in the patient's chart in a timely manner is an important step in the consent process. However, the most appropriate action for the nurse in this situation is to verify the necessity of the surgical procedure before placing the consent in the chart. This is crucial to ensure that the patient fully understands the procedure they are consenting to and that it is medically necessary. Verifying the necessity of the surgical procedure helps in preventing unnecessary procedures, promoting patient safety, and adhering to ethical principles.

Choice B rationale:

Verifying the necessity of the surgical procedure before placing the consent in the chart is the most appropriate action for the newly licensed nurse. This step ensures that the procedure is medically necessary, aligns with the patient's condition, and promotes informed decision-making. By confirming the necessity, the nurse upholds the principle of beneficence, ensuring the patient's well-being, and autonomy, allowing the patient to make informed decisions about their healthcare.

Choice C rationale:

Asking a family member to translate the consent into the language the patient understands might be helpful in improving the patient's understanding of the procedure. However, the primary concern in this situation is verifying the necessity of the surgical procedure. While communication is essential, it does not address the core issue of confirming the medical need for the surgery.

Choice D rationale:

Explaining the risks and benefits of the surgical procedure prior to getting a signature is a vital step in the consent process. However, the question specifically asks for the most appropriate action, which is to verify the necessity of the procedure. Explaining the risks and benefits is an important follow-up step after ensuring the procedure's necessity.

Choice A rationale:

"I'm sorry, I didn't hear what you said about your job. Please tell me again.”. This response demonstrates active listening and empathy. It acknowledges the patient's feelings and encourages them to share their concerns, promoting therapeutic communication. By asking the patient to repeat what they said, the nurse shows genuine interest in understanding the patient's emotions and concerns, fostering trust and rapport.

Choice B rationale:

"Why are you crying so hard about your job? What happened to your job?" This response, while well-intentioned, may come across as intrusive and judgmental. It does not encourage open communication and may make the patient feel defensive, hindering the nurse-patient relationship.

Choice C rationale:

"It's natural to be worried about your job. We all worry about our jobs sometimes.”. While this response acknowledges the patient's feelings, it does not address the specific concern the patient mentioned. It generalizes the situation and does not invite the patient to share more about their feelings, missing an opportunity for deeper communication and understanding.

Choice D rationale:

"Your job must be important to you since you are talking about it.”. This response makes an assumption about the importance of the patient's job without allowing the patient to express their feelings. It does not demonstrate active listening or empathy and may not encourage the patient to open up further about their concerns.