Level: Clinical
Difficulty: Medium
Subtopic: Confidentiality and HIPAA
NCLEX: A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to confidentiality an…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 64-year-old client on a medical-surgical unit is being evaluated for nursing care related to confidentiality and hipaa. Assessment data include family requests lab results by phone without verified authorization. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.