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 B

Explanation

Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

A. Violation of justice B. Assault C. Invasion of privacy D. False imprisonment

Correct Answer is D

Explanation

Choice A reason: Violation of justice is not a specific legal term used in civil actions. It generally refers to an unfair act or omission but is not applicable to this scenario where specific legal actions are being considered.

Choice B reason: Assault involves creating a fear of imminent harmful or offensive contact. While restraining the client could involve assault, the primary legal issue here is the unlawful confinement of the client.

Choice C reason: Invasion of privacy involves intrusion into someone's personal life without consent. This situation does not relate to privacy invasion but rather to the client's right to freedom and autonomy.

Choice D reason: False imprisonment occurs when someone is confined or restrained against their will without legal justification. The nurse's refusal to restrain the client is appropriate as forcibly restraining a competent client who wishes to leave the hospital would constitute false imprisonment.

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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

The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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