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","B","C"]

Explanation

A) Blood pressure 150/90: This data is objective because it is a measurable value obtained through direct observation using a sphygmomanometer. It provides a quantifiable assessment of the client's cardiovascular status and can be verified by others, making it an important piece of objective data.

B) Bowel sounds present in all 4 quadrants: The assessment of bowel sounds is objective as it involves physical examination techniques that can be observed and documented by the nurse. The presence of bowel sounds indicates gastrointestinal activity, and this finding can be consistently assessed across different healthcare providers.

C) PERRLA: The abbreviation stands for "Pupils Equal, Round, Reactive to Light and Accommodation." This assessment is objective as it involves specific, observable measurements of the client's pupils during an eye examination. It can be consistently evaluated by different healthcare professionals, ensuring reliable documentation.

D) Anxious about surgical procedure: This statement is subjective as it reflects the client's personal feelings and emotional state. While important for understanding the client's experience, it cannot be measured or observed directly by the nurse and relies on the client's self-reporting.

E) Dyspnea on exertion: While dyspnea can be observed, the phrase "on exertion" refers to the client's subjective experience of breathlessness. Although it can be assessed through observation of respiratory patterns, the experience itself is based on the client's interpretation, making it subjective data.

A. Anterior to the elbow. B. Distal to the elbow. C. Proximal to the elbow. D. Inferior to the elbow.

Correct Answer is C

Explanation

A) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.

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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

The nurse is completing their documentation for the shift. Which of the data is objective? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

Correct Answer is C

Explanation

What signs and symptoms indicate hypoxia? Select all that apply.

When assessing the abdomen, the nurse would expect to auscultate which sounds?

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What is the main purpose of the health assessment?