A nurse is performing the behavioral assessment of the general survey. Which assessment should the nurse include related to behavior?

A. "It's important to store client charts and documents in a secure location when not in use.": Storing charts securely prevents unauthorized access and protects client privacy. This demonstrates proper understanding of confidentiality practices in nursing documentation.

B. "I can share a client's medical information with my friends as long as I don't disclose the client's name.": Sharing any client information with unauthorized individuals violates HIPAA and confidentiality standards. Even without a name, details about a client’s condition are considered protected health information and must not be shared.

C. "We should use client identifiers such as full name and date of birth on every page of the client's chart.": Including client identifiers on each page ensures accuracy, proper record-keeping, and reduces errors. This practice supports both patient safety and legal documentation requirements.

D. "When discussing client information, we should use private and secure areas to prevent unauthorized access.": Conducting discussions in secure, private areas prevents accidental disclosure of confidential information. This demonstrates adherence to best practices for maintaining client privacy and confidentiality.

Safe:
• A nurse cleans their stethoscope before auscultating the client's lungs
• A nurse raises the bed to waist level when completing a physical assessment
• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall
• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze

Unsafe:
• A nurse administers medication to a client despite the name on the ID band not matching what the client said
• A client's family lowers all of the side rails on the bed of a client who is on fall precautions

Rationale

• A nurse cleans their stethoscope before auscultating the client's lungs: Cleaning the stethoscope reduces the risk of transmitting pathogens between clients, promoting infection control. This is a standard safe practice in clinical care.

• A nurse raises the bed to waist level when completing a physical assessment: Raising the bed to waist level allows the nurse to maintain proper body mechanics and reduce risk of musculoskeletal injury. This is consistent with safe patient handling protocols.

• An unlicensed assistive personnel (UAP) helps a client with a steady gait use a cane to ambulate down the hall: Assisting a client who is stable and using a mobility aid is safe, as long as the UAP follows proper techniques and ensures the client’s stability during ambulation.

• The nurse covers their mouth and nose with their upper arm and elbow during a sneeze: Using the elbow or upper arm to cover a sneeze prevents the spread of respiratory droplets, reducing infection risk. This is recommended over using hands, which can contaminate surfaces.

• A nurse administers medication to a client despite the name on the ID band not matching what the client said: Administering medication without verifying the correct identity violates the “right patient” safety protocol. This can result in medication errors and harm, making it unsafe.

• A client's family lowers all of the side rails on the bed of a client who is on fall precautions: Lowering side rails for a patient at fall risk increases the likelihood of injury from falls. Side rails should be maintained according to the patient’s safety plan, making this action unsafe.