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 B

Explanation

A. The client covers electrical cords with a throw rug: This action is unsafe. Placing a throw rug over electrical cords poses a fire hazard and could lead to tripping. Electrical cords should be secured and kept out of walkways to prevent accidents.

B. The client set the water heater to 49 degrees Celsius (120 degrees Fahrenheit): The water heater should be set to a maximum temperature of 49°C (120°F) to prevent scalding injuries, which are a concern for older adults whose skin may be more sensitive. Temperatures higher than this increase the risk of burns.

C. The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit): This temperature is too high. A refrigerator should be set at or below 4°C (40°F) to properly preserve food and prevent bacterial growth. Setting the refrigerator to 7.2°C (45°F) can result in foodborne illnesses.

D. The client has a standard height toilet seat in the bathroom: This may be inadequate for older adults, particularly those with mobility issues. A raised toilet seat may be recommended for better comfort and safety, as it reduces the risk of falls while sitting down or standing up.

A. “If you have the procedure now, you won’t have to deal with pai and disability later.” B. “I understand, and it’s not too late to change your mind.” C. “Why didn’t you discuss your concerns with your provider?” D. “You’ll be fine. You’ll receive a prescription for pain medication.”

Correct Answer is B

Explanation

a. "If you have the procedure now, you won’t have to deal with pain and disability later."

This response dismisses the client's concerns about pain and focuses solely on the potential benefits of the surgery. It fails to address the client's apprehension and does not provide support or empathy. Furthermore, it oversimplifies the situation and may come across as dismissive of the client's feelings.

b. “I understand, and it’s not too late to change your mind.”

This response demonstrates empathy and validation of the client's concerns. It acknowledges the client's autonomy and gives them the option to reconsider without judgment or pressure. It encourages open communication between the nurse and the client, fostering a supportive environment.

c. “Why didn’t you discuss your concerns with your provider?”

This response may come across as accusatory or blaming, which can further distress the client. It does not offer immediate support or validation of the client's concerns. While discussing concerns with the provider is important, this response fails to address the client's immediate distress and need for reassurance.

d. “You’ll be fine. You’ll receive a prescription for pain medication.”

This response minimizes the client's concerns by reassurance without addressing the underlying issue. It also assumes that pain medication will resolve all concerns related to pain, which may not be the case for the client. Additionally, it overlooks the client's emotional needs and autonomy in decision-making.

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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?

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