Nokea
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.
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A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is a therapeutic nursing response?
- A. "Your husband is making really good progress."
- B. "Crying helps us let things out and we feel better."
- C. "Did your husband say something to upset you?"
- D. "Tell me what’s concerning you."
Correct Answer: D
Rationale: Encouraging the spouse to verbalize concerns supports therapeutic communication.
A nurse is observing a newly licensed nurse as she interacts with a client regarding his concerns about his relationship with his partner. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. "Tell me about the concerns that you have regarding your relationship."
- B. "You should try to see your partner’s point of view before your own."
- C. "We could develop a plan for how to talk about this with your partner."
- D. "Relationship difficulties are stressful and require effort to resolve."
Correct Answer: B
Rationale: The correct answer is B. This statement implies a bias towards the partner's perspective, potentially invalidating the client's feelings. The nurse should prioritize understanding the client's concerns first. A is correct as it encourages open communication. C shows proactive problem-solving. D acknowledges the challenges of resolving relationship issues.
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?
- A. Rotate assignment of daily caregivers.
- B. Provide an activity schedule that changes from day to day.
- C. Limit time for the client to perform activities.
- D. Talk the client through tasks one step at a time.
Correct Answer: D
Rationale: Clients with Alzheimer's benefit from structured routines and step-by-step guidance.
How should a nurse address compulsive behaviors in a newly admitted client with OCD?
- A. Isolate the client
- B. Confront the client about the behavior
- C. Encourage participation in group activities
- D. Set strict limits on behaviors
- E. Allow additional time for rituals
Correct Answer: D
Rationale: Correct Answer: D. Set strict limits on behaviors
Rationale:
1. Setting strict limits helps establish boundaries and structure for the client.
2. It assists in reducing compulsive behaviors by providing clear guidelines.
3. It promotes a sense of control and safety for the client.
4. Allows for gradual exposure and response prevention therapy.
Summary:
A: Isolating the client can exacerbate feelings of loneliness and increase anxiety.
B: Confrontation may trigger defensiveness and hinder therapeutic rapport.
C: While group activities can be beneficial, they may not directly address the compulsive behaviors.
E: Allowing additional time for rituals reinforces maladaptive behaviors.
A nurse is caring for a group of clients. The nurse should recognize that which of the following clients is at risk for a vitamin B deficiency?
- A. A client who takes gabapentin as part of treatment for a seizure disorder.
- B. A client who has asthma.
- C. A client who has chronic alcohol use disorder.
- D. A client who takes heparin to prevent deep vein thrombosis.
Correct Answer: C
Rationale: The correct answer is C: A client who has chronic alcohol use disorder. Chronic alcohol use can lead to malabsorption of essential vitamins, including vitamin B. Alcohol interferes with the absorption and utilization of vitamin B, leading to a deficiency. This can result in various neurological and hematological complications. Clients with chronic alcohol use disorder are at high risk for vitamin B deficiency and should be closely monitored.
Incorrect Choices:
A: Gabapentin is not directly related to vitamin B deficiency.
B: Asthma does not directly increase the risk of vitamin B deficiency.
D: Heparin does not impact vitamin B levels significantly.