A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?

Document the event in the client's progress notes.

Submit an incident report to the risk manager.

Inform the client of the APs' actions.

Tell the APs to stop the conversation.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D.

Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.

Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.

Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.

Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.

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Correct Answer is D

Explanation

Choice A rationale:

Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.

Choice B rationale:

Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.

Choice C rationale:

Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.

Choice D rationale:

Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.

A. Identification. B. Reaction formation. C. Regression. D. Rationalization.

Correct Answer is D

Explanation

Choice A rationale:

Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.

Choice B rationale:

Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.

Choice C rationale:

Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.

Choice D rationale:

Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted.
Which of the following actions should the nurse take?