While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

"I am sorry you feel that way. Perhaps you'd like to return when you have more time."

"You sound angry. Would you like to tell me about it?"

Ignore the angry outburst and continue with the history questions.

Move closer and place a hand on the client's shoulder to demonstrate concern.

Answer and Explanation

The Correct Answer is B

A. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

While this response acknowledges the client's feelings, it may inadvertently dismiss the client's concerns and fail to address the immediate need for treatment. It's important for the nurse to engage with the client and explore their concerns rather than suggesting they come back later.

B. "You sound angry. Would you like to tell me about it?"

This response demonstrates empathy and acknowledges the client's emotions. By inviting the client to express their feelings further, the nurse opens the door for communication and understanding. It allows the nurse to explore the underlying reasons for the client's frustration and address their concerns.

C. Ignore the angry outburst and continue with the history questions.

Ignoring the client's emotional outburst may cause the client to feel unheard or invalidated, potentially escalating the situation further. It's essential for the nurse to address the client's concerns and emotions to maintain a therapeutic relationship and provide effective care.

D. Move closer and place a hand on the client's shoulder to demonstrate concern.

While physical touch can be comforting for some individuals, it's important to consider the client's preferences and boundaries, especially in a situation where the client is expressing frustration or impatience. Approaching the client physically without consent may not be appropriate and could further exacerbate the situation.

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Correct Answer is B

Explanation

A: Ask when the adolescent was last seen in the clinic. This option might help confirm the identity and recent activity of the patient, but it does not address the primary issue of confidentiality and privacy regarding the adolescent's medical information. Simply asking when the adolescent was last seen does not change the legal requirement to obtain consent from the patient who is now an adult.

B: Explain that the information cannot be released without the 18-year-old's permission. This is the most appropriate response. Once an individual turn 18, they are legally an adult and their health information is protected under the Health Insurance Portability and Accountability Act (HIPAA) in the United States, or similar privacy laws in other countries. Without explicit permission from the 18-year-old patient, the nurse cannot legally release medical information to anyone else, including parents.

C: Tell the mother to have the teenager call the clinic. While this response encourages the teenager to take responsibility for their own healthcare, it does not address the immediate concern of the mother inquiring about the results. It shifts the responsibility to the adolescent but doesn't explain why the mother cannot be given the information. It's a partial solution but lacks clarity on the confidentiality issue.

D: Since the serum samples were drawn last week, provide the mother with the findings. This option is inappropriate and violates HIPAA regulations. Regardless of when the serum samples were drawn, the patient is now legally an adult and the information cannot be shared without their explicit consent. Providing the mother with the findings would be a breach of the adolescent's privacy and legal rights.

A. A bubbling sound heard during inspiration and expiration in the central airways. B. A crowing noise heard during inspiration over the trachea. C. Popping, nonmusical sounds heard in the lung bases, usually during inspiration. D. Superficial squeaking or grating sounds heard during inspiration and expiration.

Correct Answer is C

Explanation

A. A bubbling sound heard during inspiration and expiration in the central airways: This description is accurate. Crackles (also called rales) are often heard in conditions like pulmonary edema or pneumonia.

B. A crowing noise heard during inspiration over the trachea: This description refers to stridor, not crackles. Stridor occurs due to upper airway obstruction.

C. Popping, non-musical sounds heard in the lung bases, usually during inspiration: This description is accurate for crackles. They occur due to fluid or secretions in the alveoli.

D. Superficial squeaking or grating sounds heard during inspiration and expiration: This description refers to wheezes, not crackles. Wheezes are associated with narrowed airways.

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While the nurse is taking a health history, the client announces, "I don't have time for this. This is a waste of time. I need treatment." Which response is best for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent's mother calls the primary healthcare provider's office to Inquire about the results of her daughter's serum test results that were drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?

Correct Answer is B

Explanation

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

Correct Answer is C

Explanation

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