A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Decline documenting the first counseling session.

Communicate expected behavior to the AP.

Explain to the AP the consequences of the behavior.

Allow the AP time to respond to the counseling information.

Conduct the counseling session with another AP present.

Answer and Explanation

Correct Answer : B,C,D

A.   Decline documenting the first counseling session: Documentation is necessary to maintain accurate records of counseling sessions.
B.   Communicate expected behavior to the AP: Reinforcing the expectations helps clarify appropriate behavior.
C.   Explain to the AP the consequences of the behavior: Understanding potential consequences encourages adherence to confidentiality standards.
D.   Allow the AP time to respond to the counseling information: Allowing the AP to respond fosters a two-way communication approach and encourages accountability.
E.   Conduct the counseling session with another AP present: Counseling sessions should remain private to maintain confidentiality.

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Correct Answer is D

Explanation

A. Provide the client with a list of community resources: Important but not the priority. Ensuring the client can perform ADLs independently or with assistance is more urgent.
B. Reinforce teaching about the client's prescribed medications: Necessary but not the priority. Safe medication management should come after addressing functional limitations.
C. Encourage the client to discuss nutritional needs with a dietitian: Important for long-term health but not immediate. ADL support is more critical.
D. Recommend occupational therapy referral for the client: Occupational therapy can address the client's difficulty with ADLs and promote independence, making this the priority.

A. "The client is 2 hours postoperative following a cholecystectomy." B. "The client rates her pain at a 3 on a 0 to 10 pain rating scale." C. "The client has type 2 diabetes mellitus." D. "The client should wear compression stockings."

Correct Answer is B

Explanation

A. "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B. "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C. "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D. "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.

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A nurse is reinforcing teaching with a newly licensed assistive personnel (AP) who has violated a client's confidentiality. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to discharge a client who had a cerebrovascular accident and has left-sided weakness. The client is having difficulty completing ADLs. Which of the following is the priority action by the nurse?

Correct Answer is D

Explanation

A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

Correct Answer is B

Explanation

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