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: While it is important to prepare the postoperative client for discharge and ensure they understand how to take their new medication, this situation is less urgent than addressing a potential respiratory issue.

Choice B reason: Changing the dressing on a recent surgical incision is part of routine care and can be scheduled after more urgent needs are addressed. The client’s wound care is important, but it does not take precedence over potential respiratory distress.

Choice C reason: Although the chest x-ray is necessary to confirm the correct placement of the nasogastric tube, this can be done after the more immediate concern of a respiratory issue is addressed. The nasogastric tube will remain in place for feeding or drainage in the meantime.

Choice D reason: This client should be assessed first because asthma can lead to respiratory distress or an asthma attack, which requires prompt intervention. Since the client requested a nebulizer treatment during the previous shift, it is crucial to assess their current respiratory status and administer the treatment if necessary to prevent any complications.

A. Black B. Green C. Red D. Yellow

Correct Answer is C

Explanation

Choice A reason: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.

Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.

Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigned to care for four clients. Which client should the nurse assess first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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