Nokea
A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
- A. Inform the client of consequences.
- B. Speak slowly in a low, calm voice.
- C. Forbid the client from speaking in an abusive manner.
- D. Remain a distance of 1 ft away from the client.
Correct Answer: B
Rationale: Speaking calmly helps de-escalate aggression.
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A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?
- A. "The legal requirement for client confidentiality ceases if the client is deceased."
- B. "Staff members are required to divulge information to attorneys if they call for information."
- C. "Health care workers are not required to answer a court's requests for information about a client's disclosure."
- D. "Providers are required to warn individuals if the client threatens harm."
Correct Answer: D
Rationale: The correct answer is D because it refers to the duty to warn, which is a legal exception to client confidentiality. When a client poses a serious and imminent threat of harm to others, healthcare providers have a duty to warn those at risk. This exception prioritizes public safety over confidentiality.
Explanation of why other choices are incorrect:
A: Incorrect. Confidentiality typically extends even after a client's death to protect their privacy rights and maintain trust in healthcare providers.
B: Incorrect. Disclosing information to attorneys without client consent violates confidentiality unless required by law or court order.
C: Incorrect. Healthcare workers are generally required to comply with court requests for information unless protected by a legal privilege.
E, F, G: Not provided.
A nurse is caring for a client who has schizophrenia. The client states, "The government is forcing thoughts into my brain through satellites." The nurse should document that the client is experiencing which of the following types of delusions?
- A. Persecution
- B. Erotomanic
- C. Somatic
Correct Answer: A
Rationale: Persecutory delusions involve irrational beliefs that one is being targeted or harmed by external forces.
A nurse is assessing a client who has a diagnosis of conversion disorder. Which of the following is an expected finding?
- A. Frequent manic episodes.
- B. Refusal of medication due to paranoia.
- C. Preoccupation with manifestations of various illnesses.
- D. Involuntary loss of a sensory function.
Correct Answer: D
Rationale: The correct answer is D: Involuntary loss of a sensory function. In conversion disorder, physical symptoms are present without a known medical cause. This can manifest as sensory deficits such as blindness or paralysis. This finding is expected as it is a hallmark of conversion disorder. Manic episodes (A) are more indicative of bipolar disorder, medication refusal due to paranoia (B) may be seen in conditions like schizophrenia, and preoccupation with various illnesses (C) is characteristic of somatic symptom disorder. Therefore, the correct choice is D as it aligns with the presentation of conversion disorder.
A nurse is assigning a room to a client who is experiencing a manic episode. Which of the following is the most appropriate room selection?
- A. A room adjacent to the nursing station
- B. A room without a window
- C. A room with dim lighting
- D. A room containing personal belongings
Correct Answer: A
Rationale: A room close to the nursing station allows for close monitoring and quick intervention if necessary.
A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following responses should the nurse make?
- A. Ask him to describe what he is feeling.
- B. Give the client some reading material as a distraction.
- C. Suggest that he take a walk around the unit.
- D. Refer him to the pastoral care team.
Correct Answer: A
Rationale: The correct response is A: Ask him to describe what he is feeling. This option encourages the client to express his emotions, which can help alleviate anxiety by providing an outlet for his concerns. By actively listening and acknowledging his feelings, the nurse can establish trust and rapport, leading to better emotional support. Choice B may provide a temporary distraction but does not address the underlying anxiety. Choice C may be physically beneficial but does not address the client's emotional state. Choice D may be helpful for spiritual support but does not directly address the client's anxiety.