The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

"Being her friend, you know she is having a difficult time and deserves her privacy."

"Only because you're worried about a friend, I'll tell you that she is improving."

"I cannot discuss any client situation with you."

"If you want to know about Mary, you need to ask her yourself."

Answer and Explanation

The Correct Answer is C

Choice A reason: This response acknowledges the friend's concern and respects Mary's privacy, but it implies that Mary is indeed having a difficult time, which is a breach of confidentiality. The nurse should not provide any information about the client's situation, even indirectly.

Choice B reason: This response directly shares information about Mary's condition, which is a violation of client confidentiality. The nurse must not disclose any details about a client's health status to someone who is not authorized to receive that information, regardless of their relationship with the client.

Choice C reason: This response is the most appropriate because it clearly states that the nurse cannot discuss any client situation. It respects client confidentiality and adheres to professional and legal standards of privacy.

Choice D reason: While this response directs the neighbor to ask Mary directly, it avoids the issue of confidentiality by not giving any information. However, it is less clear and professional compared to simply stating that the nurse cannot discuss client situations. The response should be straightforward and focused on upholding confidentiality.

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Correct Answer is D

Explanation

Choice A reason: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening. Therefore, the red category is not applicable.

Choice B reason: The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring.

Choice C reason: The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category. Therefore, this category is not suitable for the client's condition.

Choice D reason: The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.

A. Reassess the client when the provider arrives to obtain the informed consent. B. Notify the provider of the client's orientation. C. Call the nursing supervisor to give consent for the surgery. D. Ask another nurse to witness the informed consent.

Correct Answer is B

Explanation

Choice A reason: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made.

Choice B reason: Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent.

Choice C reason: Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client.

Choice D reason: Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.

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The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

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Naxlex Comprehensive Predictor Exams

A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

The emergency department nurse manager would like to develop a mass casualty drill to help with the training of the staff. What other hospital departments should be involved in the drill planning process? (Select All that Apply)

The nurse is reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

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