Nokea
A nurse is providing teaching about confidentiality with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. "The courts might require me to discuss confidential information."
- B. "I am required to provide confidential information to insurance companies."
- C. "If questioned during a police investigation, I am required to divulge confidential information."
- D. "I am legally allowed to discuss confidential information with the client's former therapist."
Correct Answer: A
Rationale: Confidentiality may be broken if required by law, such as with a court order.
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A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.
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 in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I'm being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?
- A. "Why do you feel that you need to leave?"
- B. "You feel that you don't belong here?"
- C. "We are here to help you and give you the care that you need right now."
- D. "Try to take some deep breaths and I'm sure you'll feel better."
Correct Answer: C
Rationale: The correct response is C: "We are here to help you and give you the care that you need right now." This response acknowledges the client's feelings, reassures them of support, and validates their experience without dismissing their concerns. It promotes a therapeutic relationship and trust-building.
Choice A is incorrect as it does not address the client's immediate distress. Choice B is also incorrect as it may come across as invalidating the client's feelings. Choice D is incorrect as it suggests a quick fix without addressing the client's underlying concerns.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
- A. The client is a danger to herself or others.
- B. The client is unwilling to accept that treatment is needed.
- C. The client states that she does not like the neighbor.
- D. The client states that she plans to move out of the state immediately.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse can keep the client in the hospital after the 72-hour hold if the client is deemed a danger to herself or others. This is crucial in ensuring the safety of the client and others. It indicates that the client poses a significant risk of harm, warranting further evaluation and treatment.
Incorrect Choices:
B: The client's willingness to accept treatment is important, but it does not solely determine if the client can be kept in the hospital.
C: Personal preferences or dislikes are not sufficient reasons to detain a client after the hold is over.
D: Planning to move out of the state does not address the immediate safety concerns that necessitate continued hospitalization.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.