Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

Share information only with the family.

Have a clinical reason for reading the record.

Provide information only to another nurse.

Provide information only to an attorney.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Sharing information only with family members violates confidentiality unless the patient has provided explicit consent. The Health Insurance Portability and Accountability Act (HIPAA) protects patient health information from unauthorized disclosure, even to family, without patient permission.

Choice B rationale

Adherence to confidentiality principles mandates that healthcare professionals access patient medical records only when there is a legitimate clinical reason related to the provision of care for that specific patient. Accessing records out of curiosity or without a direct care responsibility is a breach of confidentiality.

Choice C rationale

Providing information only to another nurse is too restrictive. Confidentiality allows for the sharing of necessary patient information with all members of the healthcare team directly involved in the patient's care, not just nurses.

Choice D rationale

Providing information only to an attorney is incorrect. While patient records may be disclosed to attorneys in specific legal situations with proper authorization (e.g., subpoena, patient consent), healthcare professionals can also share information with other authorized individuals involved in the patient's care.

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Correct Answer is B

Explanation

Answer and explanation

The correct answer is Choice B.

Choice A rationale

Speculating about the cause of the fall ("probably urinated on the floor") is unprofessional and lacks factual basis. Charting should be objective and based on observed facts, not assumptions.

Choice B rationale

Documenting objective observations, such as finding the patient on the floor with the urinal nearby, provides a factual account of the incident without making assumptions or assigning blame. This allows for a more accurate analysis of potential contributing factors.

Choice C rationale

Commenting on the nurse assistant's work habits ("always took her time") is subjective, irrelevant to the fall incident itself, and unprofessional. Charting should focus on the patient and the event.

Choice D rationale

Describing the patient as "grouchy and inappropriate" is judgmental, subjective, and does not contribute to an understanding of the fall. Such personal opinions are inappropriate for medical documentation.

A. Physician. B. Patient. C. Nurse. D. Therapist.

Correct Answer is C

Explanation

Choice A rationale

The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.

Choice B rationale

The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.

Choice C rationale

The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.

Choice D rationale

Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.

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Adherence to the concept of confidentiality for the patient's medical record requires that the nurse:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing the charting after a patient suffered a fall.Which statement is appropriate for the nurse to include in the description of the incident?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

The documentation that reflects implementation is:

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