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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Calling the provider is important, but it is not the immediate priority. Before contacting the provider, the nurse needs to assess the client's condition to provide accurate information about any potential adverse effects of the medication error.
Choice B reason: Notifying risk management is a necessary step in reporting the medication error, but it should be done after ensuring the client's safety and stability. Immediate patient assessment takes precedence.
Choice C reason: Checking the client's vital signs is the priority action because it allows the nurse to assess the client's current condition and identify any immediate adverse effects of the medication error. This information is critical for determining the appropriate next steps and ensuring the client's safety.
Choice D reason: Completing an incident report is essential for documenting the medication error, but it should be done after addressing the client's immediate needs and ensuring their safety. The nurse's first responsibility is to assess and manage the client's condition.
Correct Answer is B
Explanation
Choice A reason: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements.
Choice B reason: This client received tissue plasminogen activator (tPA) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority.
Choice C reason: The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care.
Choice D reason: The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tPA. While aspirin is important for preventing further strokes, it does not require the same level of immediate monitoring as the post-tPA client.
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