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 A

Explanation

Choice A Reason:

"I might have headaches due to a decline in my estrogen levels." Is appropriate. During perimenopause, fluctuations and eventual decline in estrogen levels can contribute to various symptoms, including headaches or migraines, due to hormonal changes. This statement reflects an awareness of one of the possible effects of changing hormone levels during this stage.

Choice B Reason:

"The best time to perform a breast self-examination is on the first day of my period." Is not appropriate. While performing a breast self-examination regularly is essential for breast health, the first day of the period isn't necessarily the "best" time for everyone. It's more advisable to choose a consistent day each month that is convenient and easy to remember.

Choice C Reason:

"I can expect to have regular periods until I am in menopause." Is not appropriate. Perimenopause is characterized by irregular periods, which means that during this transitional phase, menstrual cycles often become less predictable in terms of timing, duration, and flow. Irregular periods are a hallmark of perimenopause, so expecting regularity until menopause is not accurate.

Choice D Reason:

"I should stop receiving Papanicolaou tests once I reach menopause." Is not appropriate. Papanicolaou (Pap) tests are essential for detecting cervical abnormalities, regardless of menopausal status. Women should continue to have regular Pap tests according to their healthcare provider's recommendations, as the risk of cervical cancer persists even after menopause.

A. Measure the intake and output of a client who has received furosemide. B. Reinforce teaching with a client about crutch-gait walking. C. Check a client's peripheral IV site for redness or swelling. D. Assess the pain level of a client who has received acetaminophen.

Correct Answer is A

Explanation

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

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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 a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

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