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The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
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The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.
The community health nurse has been notified of several incidents. Which situation requires immediate follow-up? A client with
- A. pulmonary tuberculosis (TB) is still testing positive despite 2 months of treatment.
- B. hepatitis A who works as a cook at a local healthcare facility.
- C. human immunodeficiency virus (HIV) with an undetectable viral load (VL) and reports having recent unprotected sexual intercourse.
- D. Lyme disease and is refusing further treatment with intravenous antibiotics because of nausea and vomiting.
Correct Answer: B
Rationale: Hepatitis A in a cook (B) poses an immediate public health risk due to potential foodborne transmission, requiring urgent follow-up. Persistent TB (A), HIV with undetectable load (C), and Lyme disease refusal (D) are less immediate threats.
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.
The nurse is in an elevator and overhears two staff members discussing a client's condition. Which ethical principle does the nurse recognize may be potentially violated by this conversation?
- A. Beneficence
- B. Confidentiality
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Discussing a client’s condition in public violates confidentiality (B), as it breaches HIPAA and the client’s right to privacy. Beneficence (A), autonomy (C), and veracity (D) are unrelated to unauthorized disclosure of health information.