A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

"I cannot confirm or deny that we have a client by that name."

"I will tell him you called."

"The client's condition is stable right now."

"He is here in the hospital, but I cannot tell you anything else."

Answer and Explanation

The Correct Answer is A

Choice A Reason:

"I cannot confirm or deny that we have a client by that name." is correct. Respecting patient confidentiality is crucial in healthcare. Revealing any information about a patient's condition without proper authorization or consent could breach confidentiality laws, such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Therefore, providing minimal to no information over the phone to an unidentified caller is the appropriate approach to safeguard the patient's privacy.

Choice B Reason:

"I will tell him you called." Is incorrect. This response implies that the nurse will pass along the information or the fact that the employer called, potentially breaching the patient's confidentiality by confirming the client's presence in the hospital to an unauthorized person.

Choice C Reason:

"The client's condition is stable right now." Is incorrect. Revealing any information about the patient's condition to someone who hasn't been authorized to receive such information can breach patient confidentiality. Even stating that the condition is stable discloses some level of the patient's health status without proper consent.

Choice D Reason:

"He is here in the hospital, but I cannot tell you anything else." Is incorrect. While this response acknowledges the patient's presence in the hospital, it also hints that the nurse has information about the patient. It doesn't adhere to the standard of patient confidentiality, potentially breaching the patient's privacy.

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Correct Answer is C

Explanation

Training the bladder by voiding every 5 hr. is incorrect. For individuals experiencing urinary incontinence, scheduled voiding at regular intervals might be a part of the management plan. However, the specific interval of every 5 hours might not suit everyone, as it depends on individual bladder capacity and function. Scheduled voiding should be tailored to the individual's needs and not solely based on a fixed time frame.

Choice B Reason:

Applying adult diapers at bedtime is incorrect. While using protective garments like adult diapers may manage urinary incontinence during sleep, it doesn't address the underlying issue or provide a solution to improve the condition.

Choice C Reason:

Performing pelvic-muscle exercises is correct. Pelvic floor muscle exercises, also known as Kegel exercises, can help strengthen the muscles that support the bladder and control urine flow. This can potentially improve urinary incontinence by enhancing bladder control.

Choice D Reason:

Drinking citrus juice with meals is incorrect. Citrus juices can irritate the bladder and potentially exacerbate urinary incontinence for some individuals. Advising the consumption of citrus juice might not be beneficial and could worsen symptoms in certain cases.

A. Include the family member in providing care for the client. B. Describe a personal experience with the death of a family member. C. Ask if they have had prior experience with the death of a family member. D. Suggest that the family member contact a grief counselor.

Correct Answer is C

Explanation

Choice A Reason:

Including the family member in providing care for the client is incorrect. While involving the family in care might be helpful for some, not all family members might feel comfortable or capable of participating in direct care during such an emotional and difficult time. Asking their preferences and respecting their boundaries is crucial.

Choice B Reason:

Describing a personal experience with the death of a family member is incorrect. Sharing personal experiences could potentially be inappropriate or overwhelming for the family member. It might inadvertently shift the focus away from the client's needs and emotions.

Choice C Reason:

Asking if they have had prior experience with the death of a family member is correct. This approach allows the nurse to understand the family member's prior experiences with death, providing insights into their understanding, fears, and expectations. It also helps the nurse tailor their support accordingly, acknowledging their emotions and offering assistance that aligns with their comfort level.

Choice D Reason:

Suggesting that the family member contact a grief counselor is incorrect. While grief counseling might be beneficial, suggesting it immediately might not address the family member's immediate need or desire to help in the moment. It's essential to acknowledge their offer to help and offer immediate support or guidance that aligns with their comfort level.

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A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with an older adult client who has urinary incontinence. Which of the following instructions should the nurse include? Train the bladder by voiding every 5 hr.

Correct Answer is C

Explanation

A nurse is caring for a client who is dying. One of the client's family members tells the nurse, "I need to help. What can I do?" Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has fecal incontinence. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about advance directives with a client who has terminal colorectal cancer. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reviewing the laboratory reports of four clients. Which of the following clients should the nurse expect to have a positive fecal occult blood test?

A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating." Which of the following responses should the nurse make?

A home health nurse is visiting a client who has advanced Alzheimer's disease. The client's partner states, "I miss being able to go places with my friends." Which of the following is an appropriate response by the nurse?

A nurse is collecting data from a client who has a stage 4 pressure injury. Which of the following supplies should the nurse obtain?

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, "I'm not going to take this medication because it makes me sick and dizzy." Which of the following actions should the nurse take first?