Nokea
The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality?
- A. Informing a visitor of the room number of a client admitted with pneumonia
- B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results
- C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction
- D. Informing local authorities that a client is suspected of being a victim of domestic violence
Correct Answer: B
Rationale: Sharing drug screen results with police (B) violates confidentiality without consent or legal mandate, per HIPAA. Room number (A) is not protected, HIV disclosure for care (C) is permitted, and reporting suspected abuse (D) is legally required.
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A client with a terminal illness asks the nurse about their prognosis. The nurse discusses the prognosis with the client, which the physician had previously divulged. Which ethical principle is the nurse demonstrating?
- A. Fidelity
- B. Confidentiality
- C. Beneficence
- D. Veracity
Correct Answer: D
Rationale: Discussing the prognosis truthfully (D) demonstrates veracity, the ethical principle of truth-telling. Fidelity (A) is keeping promises, confidentiality (B) protects information, and beneficence (C) promotes well-being, but veracity is most relevant here.
The nurse has become aware of the following client situations. The nurse should first follow up with which client? A client
- A. with a chest tube that has tidaling in the water seal chamber.
- B. that is receiving mechanical ventilation and is occasionally biting on the tube.
- C. that is receiving albuterol via a nebulizer and reports headache and nervousness.
- D. with pneumonia that has become restless and confused.
Correct Answer: D
Rationale: Restlessness and confusion in pneumonia (D) suggest hypoxia or worsening infection, requiring immediate follow-up to prevent deterioration. Chest tube tidaling (A) is normal, tube biting (B) is concerning but less acute, and albuterol side effects (C) are expected.
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.
The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
The nurse cares for an unconscious client with a dissecting aortic aneurysm that needs urgent surgery. The client's family cannot be tracked. The nurse's priority action is:
- A. Send the client to surgery.
- B. Call the hospital lawyer.
- C. Search for all the client's contacts who can provide informed consent.
- D. Notify the nursing supervisor on-call and request their permission to waive informed consent.
Correct Answer: A
Rationale: For a life-threatening dissecting aortic aneurysm requiring urgent surgery, sending the client to surgery (A) is the priority under implied consent, as delay could be fatal. Contacting a lawyer (B), searching for contacts (C), or notifying the supervisor (D) delays critical intervention.