,A minister approaches a nurse caring for a client who is a member of the minister's congregation. The
minister inquires as to whether the member has been made aware of his/her diagnosis. Which of the
following would be the best response by the nurse? - Answer-"I understand your concern, but have you
asked the client?"
Explanation:
The nurse must maintain confidentiality. The minister may mean well but is trying to gather information
that is confidential. The nurse should acknowledge the minister's concern and then suggest asking the
client about the reason for hospitalization. This allows the client to share with the minister whatever
information the client wants to disclose. The other options are not correct because they do not protect
the client's privacy. Telling the minister that it is not his/her business is not a decision the nurse should
be making without discussing the situation with the client.
A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse
control. The nurse caring for the client on the previous shift identified him at high risk for falls. While
making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the
client and notes no injuries. How should the nurse follow up this incident? - Answer-Notify the physician,
then document the location of the fall, physician notification, any injury, necessary follow-up, and any
changes in the care plan needed as a result of the fall.
Explanation:
The nurse should notify the physician, then document the facts related to the fall, such as the location of
the fall, physician notification, injury if any, necessary follow-up, and any changes in the care plan that
occurred as a result of the fall. The nurse shouldn't include any information that places blame on other
health care members. The fall must be reported even if the client doesn't suffer an injury.
A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk
of developing this disease? - Answer-"Maintain weight within normal limits for your body size and muscle
mass."
, Explanation:
The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin
resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor
that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus,
but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor
for developing complications of diabetes mellitus.
What should the nurse teach a client receiving vitamin D therapy for hypoparathyroidism? - Answer-
Vitamin D is taken to increase absorption of calcium.
Explanation:
A client with hypoparathyroidism has a decreased serum calcium level. Variable doses of vitamin D
preparations enhance the absorption of calcium from the gastrointestinal tract. This does not cure the
client's hypoparathyroidism. Vitamins A, C, and E are not involved with this process. Vitamin D therapy will
not assist in stabilizing potassium.
A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough
physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a
systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which
nursing diagnosis may be appropriate? - Answer-Decreased cardiac output
Explanation:
Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the
hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac
output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis
of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral
neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.
On admission to the psychiatric unit, a client with major depression reports that a family member is
physically abusive and requests that the nurse not release any personal information to anyone. When the
allegedly abusive family member calls the unit and demands information about the client's treatment,
what is the nurse's best response? - Answer-"To protect clients' confidentiality, I can't give any
information, including whether your relative is receiving treatment here."
Explanation:
The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality.
Stating that to protect clients' confidentiality no information will be given is a diplomatic response.
, Although simply telling the caller that information can't be released protects the client's confidentiality,
this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls
or that the client didn't sign an information form with the caller's name on it divulges the client's
whereabouts and status, violating confidentiality.
A health care provider is legally and ethically required to disclose certain information. Which confidential
information should the nurse disclose? - Answer-A taxi driver's diagnosis of an uncontrolled seizure
disorder to his licensing agency
Explanation:
The health care provider may lawfully disclose confidential information about a client when the welfare of
others is at stake. The health care provider is required to inform the Department of Motor Vehicles that
the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and
client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a
significant other or pregnancy to a legally separated partner do not affect the welfare of person.
The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document
that the client's abdomen: - Answer-is flat and symmetrical.
Explanation:
The client's abdomen is flat and without abnormalities.
There is no aortic pulsation (motion is client's breathing).
There is no hernia; the umbilicus is normal.
There are no markings or lines (striae) on this client's abdomen.
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the
client to prevent: - Answer-contractures.
Explanation:
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.
minister inquires as to whether the member has been made aware of his/her diagnosis. Which of the
following would be the best response by the nurse? - Answer-"I understand your concern, but have you
asked the client?"
Explanation:
The nurse must maintain confidentiality. The minister may mean well but is trying to gather information
that is confidential. The nurse should acknowledge the minister's concern and then suggest asking the
client about the reason for hospitalization. This allows the client to share with the minister whatever
information the client wants to disclose. The other options are not correct because they do not protect
the client's privacy. Telling the minister that it is not his/her business is not a decision the nurse should
be making without discussing the situation with the client.
A client experienced a right frontal stroke that left him with short-term memory loss and lack of impulse
control. The nurse caring for the client on the previous shift identified him at high risk for falls. While
making rounds to begin the shift, a nurse notices the client lying on the floor. The nurse assesses the
client and notes no injuries. How should the nurse follow up this incident? - Answer-Notify the physician,
then document the location of the fall, physician notification, any injury, necessary follow-up, and any
changes in the care plan needed as a result of the fall.
Explanation:
The nurse should notify the physician, then document the facts related to the fall, such as the location of
the fall, physician notification, injury if any, necessary follow-up, and any changes in the care plan that
occurred as a result of the fall. The nurse shouldn't include any information that places blame on other
health care members. The fall must be reported even if the client doesn't suffer an injury.
A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk
of developing this disease? - Answer-"Maintain weight within normal limits for your body size and muscle
mass."
, Explanation:
The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin
resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor
that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus,
but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor
for developing complications of diabetes mellitus.
What should the nurse teach a client receiving vitamin D therapy for hypoparathyroidism? - Answer-
Vitamin D is taken to increase absorption of calcium.
Explanation:
A client with hypoparathyroidism has a decreased serum calcium level. Variable doses of vitamin D
preparations enhance the absorption of calcium from the gastrointestinal tract. This does not cure the
client's hypoparathyroidism. Vitamins A, C, and E are not involved with this process. Vitamin D therapy will
not assist in stabilizing potassium.
A client seeks medical attention for dyspnea, chest pain, syncope, fatigue, and palpitations. A thorough
physical examination reveals an apical systolic thrill and heave, along with a fourth heart sound (S4) and a
systolic murmur. Diagnostic tests reveal that the client has hypertrophic cardiomyopathy (HCM). Which
nursing diagnosis may be appropriate? - Answer-Decreased cardiac output
Explanation:
Decreased cardiac output is an appropriate nursing diagnosis for a client with HCM because the
hypertrophied cardiac muscle decreases the effectiveness of the heart's contraction, decreasing cardiac
output. Heart failure may complicate HCM, causing fluid volume excess; therefore, the nursing diagnosis
of Risk for deficient fluid volume isn't applicable. Ineffective thermoregulation and Risk for peripheral
neurovascular dysfunction are inappropriate because HCM doesn't cause these problems.
On admission to the psychiatric unit, a client with major depression reports that a family member is
physically abusive and requests that the nurse not release any personal information to anyone. When the
allegedly abusive family member calls the unit and demands information about the client's treatment,
what is the nurse's best response? - Answer-"To protect clients' confidentiality, I can't give any
information, including whether your relative is receiving treatment here."
Explanation:
The client has the right to confidential treatment, and the nurse has a duty to protect his confidentiality.
Stating that to protect clients' confidentiality no information will be given is a diplomatic response.
, Although simply telling the caller that information can't be released protects the client's confidentiality,
this response isn't as diplomatic as the first response. Stating that the client isn't accepting phone calls
or that the client didn't sign an information form with the caller's name on it divulges the client's
whereabouts and status, violating confidentiality.
A health care provider is legally and ethically required to disclose certain information. Which confidential
information should the nurse disclose? - Answer-A taxi driver's diagnosis of an uncontrolled seizure
disorder to his licensing agency
Explanation:
The health care provider may lawfully disclose confidential information about a client when the welfare of
others is at stake. The health care provider is required to inform the Department of Motor Vehicles that
the taxi driver has an uncontrolled seizure disorder because it's in the best interest of the public's and
client's safety. Confidentiality of HIV testing is required. Disclosing a client's cancer diagnosis to a
significant other or pregnancy to a legally separated partner do not affect the welfare of person.
The nurse is inspecting the client's abdomen (see the accompanying image). The nurse should document
that the client's abdomen: - Answer-is flat and symmetrical.
Explanation:
The client's abdomen is flat and without abnormalities.
There is no aortic pulsation (motion is client's breathing).
There is no hernia; the umbilicus is normal.
There are no markings or lines (striae) on this client's abdomen.
When developing a long term care plan for the client with multiple sclerosis, the nurse should teach the
client to prevent: - Answer-contractures.
Explanation:
Typical complications of multiple sclerosis include contractures, decubitus ulcers, and respiratory
infections. Nursing care should be directed toward the goal of preventing these complications.
Ascites, fluid overload, and dry mouth are not associated with multiple sclerosis.
