A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

Complete an incident report about the breach of client confidentiality

Reassign the AP to other clients on the unit

Instruct the AP to discontinue the conversation

Notify the client’s provider about the incident

Answer and Explanation

The Correct Answer is C

a. Complete an incident report about the breach of client confidentiality:

While documenting the incident is important, completing an incident report alone may not address the immediate need to stop the breach of confidentiality.

b. Reassign the AP to other clients on the unit:

Reassignment may be considered after addressing the immediate issue, but it doesn't directly address the inappropriate conversation.

c. Instruct the AP to discontinue the conversation:

This is the correct immediate action. The nurse should intervene and instruct the assistive personnel to stop discussing the client's care in a non-secure location like the cafeteria.

d. Notify the client’s provider about the incident:

While notifying the client's provider may be necessary in certain situations, the immediate concern is to stop the breach of confidentiality and address the inappropriate conversation.

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Correct Answer is A

Explanation

a. Decreased level of consciousness:

This finding is concerning and may indicate worsening neurological status, increased intracranial pressure, or impending herniation. A decreased level of consciousness requires immediate evaluation by the provider to assess for neurological deterioration and potential interventions to stabilize the client's condition.

b. Increased temperature:

While an increased temperature (fever) is commonly associated with meningitis due to the inflammatory response, it may not necessarily require immediate reporting unless it is extremely high or accompanied by other concerning symptoms. Fever management is important, but it may not warrant immediate provider notification unless it is severe or refractory to treatment.

c. Generalized rash over trunk:

A generalized rash can be associated with certain types of meningitis, such as meningococcal meningitis, and may indicate sepsis or disseminated infection. However, it may not always require immediate provider notification unless it is accompanied by other concerning symptoms or signs of systemic illness.

d. Report of photophobia:

Photophobia (sensitivity to light) is a common symptom of meningitis and is often reported by clients. While photophobia is significant in the context of meningitis, it may not require immediate provider notification unless it is severe or accompanied by other worrisome neurological symptoms.

A. A client who is 37 weeks of gestation and has an L/S ratio of 2:1 B. A client who is at 28 weeks of gestation and has a negative Coombs’ titer C. A client who is at 39 weeks of gestation and has a negative contraction stress test D. A client who is at 35 weeks of gestation and has a biophysical profile of 6

Correct Answer is D

Explanation

a. A client who is 37 weeks gestation and has an L/S ratio of 2:1:

An L/S (Lecithin/Sphingomyelin) ratio of 2:1 indicates mature fetal lungs, which is a positive indicator. While this client may be nearing term, the presence of mature fetal lungs does not necessarily warrant an interdisciplinary care conference unless there are other complications or high-risk factors present.

b. A client who is 28 weeks gestation and has a negative Coombs's titer:

A negative Coombs's titer suggests that the client does not have antibodies against Rh-positive blood cells, which is a normal finding. At 28 weeks gestation, this client may not require an interdisciplinary care conference unless there are other significant complications or risk factors present.

c. A client who is at 39 weeks gestation and has a negative contraction stress test:

A negative contraction stress test indicates that the fetus is not experiencing distress during uterine contractions, which is a reassuring finding. At 39 weeks gestation, while this client may be nearing term, a negative contraction stress test alone may not warrant an interdisciplinary care conference unless there are other concerning factors present.

d. A client who is at 35 weeks gestation and has a biophysical profile of 6:

A biophysical profile (BPP) of 6 is on the lower end of the scale and may indicate potential fetal compromise or risk. This client may benefit from further evaluation and possibly closer monitoring, which could warrant an interdisciplinary care conference to discuss management and potential interventions.

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A nurse overhears two assistive personnel discussing a client’s care in the cafeteria. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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