A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
The ethics committee will need to approve this request for you.
I will ask the nursing supervisor to obtain the medical records for you.
The healthcare provider will share this information with you.
The client must provide permission to share the records with you.
The Correct Answer is D
Choice A reason:
The ethics committee does not typically handle requests for access to medical records. Their role is more focused on addressing ethical dilemmas and conflicts in patient care, rather than routine administrative tasks like granting access to medical records.
Choice B reason:
Asking the nursing supervisor to obtain the medical records for a family member is not appropriate without the client’s consent. Medical records are confidential and protected under laws such as HIPAA (Health Insurance Portability and Accountability Act), which require patient authorization for disclosure.
Choice C reason:
The healthcare provider cannot share medical information with a family member without the client’s explicit permission. This is to ensure the privacy and confidentiality of the client’s health information.
Choice D reason:
The correct procedure is for the client to provide permission to share their medical records. Under HIPAA, a healthcare provider can only share a patient’s medical information with family members if the patient has given explicit consent. This ensures that the patient’s privacy rights are respected and that their health information is protected.
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Correct Answer is ["A","B","C","E"]
Explanation
Choice A: Evaluate for the presence of a Babinski reflex
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants up to 2 years old. When the sole of the foot is stroked, the big toe moves upward, and the other toes fan out. This reflex helps assess the neurological function and integrity of the corticospinal tract. In the context of a subdural hematoma, evaluating the Babinski reflex can help determine if there is any neurological impairment or increased intracranial pressure, which could indicate worsening of the condition.
Choice B: Measure the head circumference
Measuring the head circumference is crucial in infants, especially those with head injuries, as it helps monitor brain growth and detect any abnormal swelling or increased intracranial pressure. An increase in head circumference can indicate the presence of intracranial bleeding or edema, which requires immediate medical attention. Regular monitoring of head circumference allows healthcare providers to track the infant’s neurological development and identify any deviations from the normal growth curve.
Choice C: Assess the pupillary reaction to light
Assessing the pupillary reaction to light is an essential neurological assessment in infants with head injuries. The pupils’ response to light provides information about the function of the optic nerve and the brainstem. A normal pupillary reaction indicates that the brainstem is functioning correctly, while an abnormal reaction can suggest increased intracranial pressure or brain injury. In this case, the nurse should assess the pupillary reaction to ensure there are no signs of neurological deterioration.
Choice D: Encourage parents to feed the infant
Encouraging parents to feed the infant is not recommended in this scenario. The infant’s inability to awaken for feeding and sleeping through the vital sign assessment could indicate a decreased level of consciousness or neurological impairment. Feeding an infant in such a state could increase the risk of aspiration and further complications. Instead, the nurse should focus on monitoring the infant’s neurological status and ensuring their safety.
Choice E: Palpate fontanel level
Palpating the fontanel level is an important assessment in infants with head injuries. The fontanels, or soft spots on the infant’s skull, provide valuable information about intracranial pressure. A bulging fontanel can indicate increased intracranial pressure, while a sunken fontanel may suggest dehydration. In this case, the nurse should palpate the fontanel to assess for any abnormalities that could indicate changes in the infant’s condition.
Correct Answer is B
Explanation
Choice A: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.