A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
Report the incident to the charge nurse.
Participate in an in-service about client confidentiality.
Tell the staff members to stop their discussion.
Speak to the staff members in private about client confidentiality.
The Correct Answer is C
a. While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.
b. Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.
c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.
d. Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hepatitis A is primarily transmitted through the fecal-oral route, often due to contaminated food or water. However, it can also spread through close personal contact, including sharing towels, utensils, or other personal items. By using different hand towels than others in the home, the client demonstrates an understanding of the importance of preventing the transmission of the virus.
While hand hygiene is essential in preventing the spread of infectious diseases, including hepatitis A, alcohol-based cleansers are not effective against the hepatitis A virus. Washing hands with soap and water for at least 20 seconds is the recommended method to remove the virus from the hands.
Hepatitis A can be spread through contaminated food, so it is important for the client to avoid preparing food for others during the acute phase of the illness and until cleared by a healthcare professional.
Hepatitis A is not typically transmitted through contact with blood. It is primarily transmitted through the fecal-oral route or close personal contact with an infected individual.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
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