While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

Reinforce the potential consequences of not having this information on record to the nursing staff.

Ask nurses who are caring for clients without this information in the medical record to obtain it.

Meet with nursing staff to review the policy regarding advance directives.

Remind nurses to obtain this information during the admission process.

Answer and Explanation

The Correct Answer is B

A.   Reinforce the potential consequences of not having this information on record to the nursing staff: While reinforcing the importance of advance directives is necessary, the immediate priority is to ensure that missing information is obtained.
B.   Ask nurses who are caring for clients without this information in the medical record to obtain it: This is the correct answer. The priority action is to address the missing documentation by
instructing nurses to obtain advance directive information from clients who lack it in their medical records.
C.   Meet with nursing staff to review the policy regarding advance directives: While policy review may be necessary, it is not the immediate action needed to address the missing documentation.
D.   Remind nurses to obtain this information during the admission process: While obtaining advance directive information during the admission process is important, the priority is to address the missing documentation for current clients.

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

Explanation

A. This is a breach of confidentiality because discussing a client's condition in a public area where unauthorized individuals can overhear is inappropriate. Confidential information should only be shared in private settings where privacy can be ensured.
B. Logging out of the computer is not a breach of confidentiality; it is a security measure to protect client information.
C. Reviewing an electronic list of clients admitted to the unit is part of routine nursing duties and does not constitute a breach of confidentiality as long as the information is not disclosed to unauthorized individuals.
D. Faxing client data to a referred provider is a part of continuity of care and is not a breach of confidentiality if done following proper protocols to ensure the information is received by the intended recipient.
E. Informing a friend of the client about their condition without consent is a breach of confidentiality. Information about a client's condition should only be shared with individuals who are authorized to receive it, typically those involved in the client's care or those the client has
given permission to be informed.

A. A client who has dementia and exhibits aphasia B. A client who has bipolar disorder and displays constant pacing C. A client who has schizophrenia and uses neologisms D. A client who has depressive disorder and has poor personal hygiene

Correct Answer is B

Explanation

A. A client who has dementia and exhibits aphasia: While aphasia can be concerning, it is not necessarily indicative of immediate risk to the client or others.
B. A client who has bipolar disorder and displays constant pacing: This client is the highest priority because constant pacing may indicate agitation or escalating anxiety, which could lead to agitation or aggression and require immediate intervention to prevent harm to the client or others.
C. A client who has schizophrenia and uses neologisms: Neologisms, although indicative of disorganized thinking, do not necessarily present an immediate safety concern compared to constant pacing.
D. A client who has depressive disorder and has poor personal hygiene: While poor personal hygiene is important to address for the client's well-being, it may not present an immediate safety risk compared to the behaviors exhibited by the client in option B.

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While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

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

Explanation

A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?

Correct Answer is B

Explanation

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While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?

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