A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

Ask the APs to discontinue the conversation.

Inform the client what has occurred.

Notify the client's provider.

Schedule a disciplinary conference for the APS.

Answer and Explanation

The Correct Answer is A

Ask the APs to discontinue the conversation:

This is the most appropriate immediate action. Discussing a client's care in a public area violates the principle of patient confidentiality. The nurse should intervene promptly and ask the assistive personnel to stop the conversation.

Inform the client what has occurred:

While transparency with the client is important, it may not be the first action to take in this situation. The priority is to address the breach of confidentiality by stopping the conversation.

Notify the client's provider:

Notifying the client's provider is not the initial action to take in this situation. First, the nurse should address the immediate issue by stopping the inappropriate conversation. The provider may be informed later, if necessary.

Schedule a disciplinary conference for the APs:

Scheduling a disciplinary conference is a step that may be taken after addressing the immediate issue. The priority is to stop the inappropriate conversation and address confidentiality concerns before considering disciplinary actions.

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Correct Answer is A

Explanation

A. Fidelity refers to the concept of keeping promises or commitments made to clients. In this scenario, the nurse is demonstrating fidelity by informing the client that they will return as soon as possible with pain medication, indicating a commitment to addressing the client's needs promptly.

B. Justice pertains to fairness and equitable distribution of resources. It is not demonstrated in this scenario where the nurse is making a commitment to address the client's pain.

C. Autonomy involves respecting the client's right to make their own decisions and choices about their care. The nurse, in this case, is not specifically addressing the client's autonomy but rather demonstrating fidelity by committing to providing pain medication.

D. Nonmaleficence is the principle of doing no harm and ensuring the client's safety. While providing pain medication aligns with nonmaleficence by addressing the client's pain, the specific action of informing the client about the intent to return promptly falls more under the principle of fidelity.

A. Engage the client in a repetitive activity as a distraction. B. Place the client in a seclusion room. C. Apply wrist restraints to the client. D. Administer PRN haloperidol IM to the client

Correct Answer is A

Explanation

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

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A nurse overhears two assistive personnel (AP) in the cafeteria discussing a client's care during lunch. Which of the following actions should the nurse take?

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