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 A

Explanation

A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.

B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.

C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.

D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.

A. Impact on ADL's. B. Family medical history. C. Pain intensity rating D. Characteristics of the pain. E. Aggravating factors.

Correct Answer is ["A","C","D","E"]

Explanation

A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.

B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.

C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.

D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.

E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.

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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

During the assessment of a client's head and neck, the nurse observes the client's facial expressions and the face for symmetry and movement. Which cranial nerve is the nurse assessing?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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