A nurse working on a psychiatric unit receives a telephone call ...

[Yi-Chen]

A nurse working on a psychiatric unit receives a telephone call from the employer of one of the clients on the unit.
 
  The employer asks to be sent a copy of Mr. Murray's latest laboratory work and psychological testing results so Mr. Murray's medical records in employee health can be kept up-to-date. Based on the nurse's knowledge about issues surrounding breach of confidentiality, which response would be the most appropriate?
 
  A) I'm sorry; we're not allowed to give out that information about our client.
  B) I'll have to get the client's signed consent before we can send that information to you.
  C) I am unable to acknowledge whether or not a Mr. Murray is a client on this unit.
  D) Sure, give me your address, and I will see that the information is sent to you.

Question 2

A nurse is providing care to a male client who is hospitalized with a diagnosis of schizophrenia. Which of the following would be appropriate for the nurse to include in the client's medical record?
 
  A) Client states that he had a good night with no complaints.
  B) Complained of being unable to sleep because he heard voices throughout the night.
  C) Had a typical night without incidence of insomnia or nightmares.
  D) Acted crazily throughout the night; kept hearing voices and noises.

[chevyboi1976]

Answer to Question 1

Ans: C
A breach of confidentiality is the release of client information without the client's consent in the absence of legal compulsion or authorization to release information. Acknowledging that Mr. Murray is a client on the unit would be such a breach. Even if the nurse explains that he or she cannot give the information without the client's consent, the explanation lets the employer know that Mr. Murray is receiving care in a psychiatric hospital.

Answer to Question 2

Ans: B
The most appropriate statement to be recorded is, Complained of being unable to sleep because he heard voices throughout the night. This statement clearly depicts the client's problem and the reason why. The nurse should avoid jargon and stereotypical statements, such as having a good night with no complaints or acting crazily. Only meaningful, accurate, objective descriptions of the behavior should be used.

[Yi-Chen]

Excellent

[helenmarkerine]

Thanks for the timely response, appreciate it