The nurse is admitting a client to the acute care unit. Which should the nurse consider when regarding the confidentiality of the client?

Information sharing is limited to those directly involved in the client's care.

All members of the units healthcare team may have access to the client's chart.

The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client.

The medical records are open to any hospital employee, including administration.

Answer and Explanation

The Correct Answer is A

A) Information sharing is limited to those directly involved in the client's care: This statement reflects the principle of confidentiality and the ethical obligation to protect the client's private health information. Only healthcare providers directly involved in the client’s care should have access to their information, ensuring that it remains secure and confidential.

B) All members of the unit's healthcare team may have access to the client's chart: While many healthcare team members need access to the client's information for care coordination, this statement is misleading. Access should be limited to those directly involved in the client’s care to protect their confidentiality.

C) The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client: While HIPAA does set guidelines for the protection of health information and governs the sharing of health data, it does not specifically determine who may communicate with the client. Instead, it focuses on protecting their privacy.

D) The medical records are open to any hospital employee, including administration: This statement is incorrect as it violates confidentiality principles. Medical records are not accessible to all hospital employees; access is restricted to authorized personnel only, ensuring that patient information is kept confidential.

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Correct Answer is B

Explanation

A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.

B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.

D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.

A. Low self-esteem B. His complaints of numbness in his hands C. Risk for injury D. Persistent pain

Correct Answer is C

Explanation

A) Low self-esteem: While low self-esteem can develop as a result of limitations in physical abilities, it is not the most immediate concern in this scenario. Addressing the patient's functional capabilities and safety takes precedence.

B) His complaints of numbness in his hands: Numbness is a significant symptom of carpal tunnel syndrome, but the immediate priority is to ensure the patient can safely perform tasks. While it is important to address his symptoms, managing the risk associated with his condition is more critical.

C) Risk for injury: This is the most pressing concern for the patient. Given his difficulty holding tools, there is a heightened risk of accidents or injuries while working. Prioritizing safety measures is essential to prevent harm and ensure he can continue his work safely.

D) Persistent pain: While pain management is important, the focus should be on the immediate risk of injury related to the patient's inability to hold tools securely. Addressing safety concerns takes precedence over managing pain at this point.

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The nurse is admitting a client to the acute care unit. Which should the nurse consider when regarding the confidentiality of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing the skin of an elderly client, the nurse notes tenting. The nurse understands what about this assessment?

Correct Answer is B

Explanation

A patient, employed as a carpenter, has difficulty holding tools because of peripheral neuropathy from carpal tunnel syndrome. What is the nurse's priority concern for this patient?

Correct Answer is C

Explanation

A patient who is diagnosed with a cervical herniated disc complains of pain. The nurse concludes that the patient's pain is caused by which of the following?

The nurse notes which of the following about the patient's skin during her morning assessment? Select all that apply.

What is the main purpose of the health assessment?

The nurse notes an exaggerated cervical curve while inspecting the spine of a client. Which term will the nurse use when documenting this finding in the medical record?

Which instructions should the nurse provide a client to assess the lateral flexion?

The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?

A resident in an assisted-living facility is restless most nights and sits in the lounge area reading. When questioned, the resident reports suffering from insomnia. What should the nurse expect as an outcome if the resident continues with this pattern of sleep?

The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?