The nurse documents on the facility's electronic documentation system
1. The nurse documents on the facility's electronic documentation system located in each client's room. Which actions by the nurse maintain confidentiality of the documented information? (Select all that apply.)
• Refuse to leave the computer screen open so that family can review.
• Shut of the computer after documenting and before leaving the room.
• Use the nurse's personal password for access to the client's record.
• Share a password so a colleague can document on the client's record.
• Explain to visitors that information about the client cannot be shared.
2. Upon assessment, the nurse notes a client has an enlarged thyroid gland. Which other assessment information does the nurse expect to find from the health history related to this condition? Select all.
• Bradycardia
• Nervousness
• Weight loss
• Constipation
• Dry coarse skin
• Exophthalmos
3. The nurse interviews a client diagnosed with substance abuse. The nurse knows which populations are at risk for abusing substances. (Select the correct answer)
• Persons who try substances at an early age.
• Persons undergoing significant stress.
• Persons who are or have been abused.
• Persons with a genetic predisposition to addiction.
• Persons living in a family with addiction.
• Persons diagnosed with clinical depression.
4. The nurse teaches the UAP about hand hygiene. Which statements does the nurse make? Select the correct answers.
• Wash hands during client care if contaminated with body fluids.
• Perform hand hygiene before removing gloves will be worn.
• Perform hand hygiene even if gloves will be worn.
• Soap and water must be used for all hand hygiene.
• Wash the hands before exiting the client’s room.
Sample Solution
Nurse actions to maintain confidentiality of documented information:
- Refuse to leave the computer screen open so that family can review.
- Shut off the computer after documenting and before leaving the room.
- Use the nurse's personal password for access to the client's record.
- Explain to visitors that information about the client cannot be shared.
Full Answer Section
Sharing passwords or allowing others to access client records without authorization is a breach of confidentiality.- Expected assessment information related to an enlarged thyroid gland:
- Bradycardia
- Nervousness
- Weight loss
- Constipation
- Dry, coarse skin
- Exophthalmos
- Bradycardia (slow heart rate)
- Nervousness
- Weight loss
- Constipation
- Dry, coarse skin
- Exophthalmos (bulging eyes)
- Other possible symptoms include:
- Neck swelling
- Difficulty swallowing
- Hoarseness
- Cough
- Headaches
- Muscle weakness
- Populations at risk for substance abuse:
- Persons who try substances at an early age
- Persons undergoing significant stress
- Persons who are or have been abused
- Persons with a genetic predisposition to addiction
- Persons living in a family with addiction
- Persons diagnosed with clinical depression
- Persons who try substances at an early age: The earlier a person begins using substances, the more likely they are to develop an addiction.
- Persons undergoing significant stress: Stressful life events, such as job loss, divorce, or the death of a loved one, can increase the risk of substance abuse.
- Persons who are or have been abused: Physical, sexual, or emotional abuse can lead to substance abuse as a coping mechanism.
- Persons with a genetic predisposition to addiction: Some people are more genetically susceptible to addiction than others.
- Persons living in a family with addiction: Children who grow up in homes with substance abuse are more likely to develop substance abuse problems themselves.
- Persons diagnosed with clinical depression: People with depression are more likely to abuse substances in an attempt to self-medicate their symptoms.
- Nurse statements about hand hygiene:
- Wash hands during client care if contaminated with body fluids.
- Perform hand hygiene before removing gloves will be worn.
- Perform hand hygiene even if gloves will be worn.
- Soap and water must be used for all hand hygiene.
- Wash the hands before exiting the client's room.
- Wet your hands with water.
- Apply enough soap to cover all hand surfaces.
- Rub your hands together for at least 20 seconds, paying attention to the backs of your hands, between your fingers, and under your nails.
- Rinse your hands thoroughly with water.
- Dry your hands completely with a clean towel.