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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.
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A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
A nurse is admitting a client who is in the manic phase of bipolar disorder. The nurse should plan to make which of the following room assignments for the client?
- A. A private room in a quiet location on the unit
- B. A semiprivate room with a roommate who has similar symptoms
- C. A private room close to the nursing station
- D. A seclusion room until the client's activity level becomes more subdued
Correct Answer: C
Rationale: The correct answer is C: A private room close to the nursing station. This choice ensures the client's safety and allows for close monitoring by the nursing staff due to the increased risk of impulsive behaviors during the manic phase. A private room helps minimize distractions and stimuli that can exacerbate manic symptoms, while proximity to the nursing station enables quick intervention if needed.
Incorrect choices:
A: A private room in a quiet location on the unit - While privacy is important, a quiet location may not provide adequate supervision and support for a client in the manic phase.
B: A semiprivate room with a roommate who has similar symptoms - Sharing a room with someone exhibiting similar symptoms may lead to escalation of behaviors and lack of supervision.
D: A seclusion room until the client's activity level becomes more subdued - Seclusion should only be used as a last resort for safety concerns and is not appropriate for managing manic symptoms.
A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?
- A. Encouraging client feedback about satisfaction with the facility experience
- B. Explaining unit rules and policies regarding unacceptable behaviors
- C. Supporting the client’s wish to refuse prescribed medications
- D. Making sure the client understands expectations for participation
Correct Answer: C
Rationale: The correct answer is C: Supporting the client’s wish to refuse prescribed medications. Autonomy refers to the client's right to make their own decisions about their care. By supporting the client's wish to refuse medications, the nurse is respecting the client's autonomy and right to make decisions about their treatment. This empowers the client to have control over their own healthcare decisions.
Explanation for incorrect choices:
A: Encouraging client feedback about satisfaction with the facility experience - This choice relates to client satisfaction but does not directly address autonomy.
B: Explaining unit rules and policies regarding unacceptable behaviors - This choice focuses on rules and policies, not autonomy.
D: Making sure the client understands expectations for participation - This choice is about ensuring understanding, not necessarily autonomy.
A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.” The nurse identifies this behavior as an example of which of the following defense mechanisms?
- A. Dissociation
- B. Introjection
- C. Regression
- D. Repression
Correct Answer: C
Rationale: The correct answer is C: Regression. Regression is a defense mechanism where an individual reverts to an earlier stage of development when faced with stressful situations. In this scenario, the client's behavior of being consistently late and avoiding responsibilities reflects a regression to a state where they feel the need to be taken care of, like a child seeking comfort from a caregiver. This behavior is a way of coping with anxiety by seeking refuge in a familiar and less demanding role. Dissociation (A) involves disconnecting from reality to avoid distress, introjection (B) is internalizing the qualities of others, and repression (D) is unconsciously suppressing unwanted thoughts or memories.