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A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can discuss a client's information with staff who have provided care in the past.
- B. A client retains the legal right to privacy of health information even after they have died.
- C. The provider must give consent to discuss health information with the client's family.
- D. A provider may speak to a client's employer regarding a substance use disorder.
Correct Answer: B
Rationale: Clients retain the legal right to privacy of health information even after death, per HIPAA regulations. This statement reflects an accurate understanding of confidentiality principles.
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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?
- A. Therapeutic hold.
- B. Restraint.
- C. Diversion.
- D. Timeout.
Correct Answer: D
Rationale: Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique. This matches the client’s request and supports de-escalation efforts.
A nurse is assisting with reminiscence therapy for a group of older adult clients. Which of the following strategies should the nurse implement?
- A. Making a unit calendar to promote orientation.
- B. Discussing childhood memories during group therapy.
- C. Encouraging thought-stopping to block undesirable thoughts.
- D. Playing board games with other clients to enhance cognition.
Correct Answer: B
Rationale: Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults. This aligns with the goals of reminiscence therapy, unlike orientation aids or thought-stopping.
A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?
- A. Loss of job.
- B. Motor-vehicle crash.
- C. Divorce.
- D. A child leaving for college.
Correct Answer: D
Rationale: A child leaving for college represents a maturational crisis, tied to normal developmental transitions that cause stress. Unlike situational crises like job loss or divorce, it reflects life stage changes.
A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?
- A. Reaction formation.
- B. Somatization.
- C. Sublimation.
- D. Intellectualization.
Correct Answer: B
Rationale: Somatization involves the transformation of anxiety into physical symptoms, such as pain or fatigue, without a medical cause. This is a way the body expresses psychological distress through physical symptoms, aligning with the client’s behavior.
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I may be more sensitive to the sun while taking this medication.
- B. The medication may cause urinary incontinence.
- C. I may experience a metallic taste while taking this medication.
- D. The medication may cause ringing in my ears.
Correct Answer: A
Rationale: Haloperidol can increase photosensitivity, causing the skin to be more sensitive to sunlight, potentially leading to sunburn. Patients should be advised to use sunscreen and wear protective clothing. This statement shows the client understands a key side effect.