Nokea
The nurse talks with a child who has been sexually abused by a family member. The child asks the nurse, 'If I tell you something, will you tell anyone my secret?' Which response by the nurse to the client is appropriate?
- A. I will not tell anyone your secret.
- B. I will not tell your mom and dad.
- C. I'll call the nursing supervisor as a witness.
- D. I cannot keep this information a secret.
Correct Answer: D
Rationale: Nurses are mandated reporters and cannot promise confidentiality in cases of abuse, as reporting to authorities is required to protect the child. This response is honest and maintains trust while adhering to legal and ethical obligations.
You may also like to solve these questions
The nurse is caring for a client who says, 'I don't want to talk with you because you're only the nurse. I'll wait for my doctor.' Which statement should the nurse say in response to the client?
- A. I'm saddened by the way you dismissed me.
- B. I understand. So should I call your primary health care provider?
- C. Your primary health care provider directs me in your nursing care.
- D. So then, you would prefer to speak with your primary health care provider?
Correct Answer: B
Rationale: The nurse uses techniques of therapeutic communication to reflect the client's statement (option 2), redirect feelings back to the client for validation, and focus on the client's desire to talk with the doctor. Options 1 and 3 are nontherapeutic responses and are defensive responses. Option 4 reinforces the client's behavior and does not encourage client expression of feelings.
A preschooler has just been diagnosed with impetigo. The child's mother tells the nurse, 'But my children take baths every day.' Which therapeutic response should the nurse make to the mother?
- A. You are concerned about how your child got impetigo?'
- B. There is no need to worry. We will not tell your day care provider why your child is absent.'
- C. Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.'
- D. You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.'
Correct Answer: A
Rationale: By paraphrasing what the parent tells the nurse, the nurse is addressing the parent's thoughts. Option 1 demonstrates the therapeutic technique of paraphrasing. The remaining options are blocks to communication because they make the parent feel guilty for the child's illness.
The nurse is caring for a client with schizophrenia who is having active hallucinations. The nurse implements which actions to manage the client during the episode? Select all that apply.
- A. administers medications as ordered
- B. uses gentle touch to reassure the client
- C. tells the client that others see or hear what he does
- D. distracts the client by placing him in the dayroom with others
- E. asks the client if he hears voices telling him to harm himself or others
Correct Answer: A,E
Rationale: Administering medications (A) helps manage hallucinations, and asking about harmful voices (E) assesses safety. Touch (B) may be misinterpreted, validating hallucinations (C) is harmful, and distraction in a dayroom (D) may overwhelm the client.
The nurse is preparing a client for a parathyroidectomy when the client states, 'I guess I'll have to wear a scarf after this surgery.' Considering this statement, which concern should the nurse address?
- A. Denial that the surgery is necessary
- B. Trouble coping with the need for surgery
- C. Issues with potential changes to body image
- D. Anxiety about postsurgical altered function
Correct Answer: C
Rationale: The client's statement reflects a psychosocial concern regarding his or her appearance after surgery, so option 3 is the correct option. The remaining options identify unsuitable problems that are not supported by the provided client data.
The nurse counsels the spouse of a client diagnosed with generalized anxiety disorder about how to cope with the client's anxiety. Which statement, made by the spouse, indicates that teaching is successful?
- A. Anxiety is a conscious means of resolving conflict.
- B. Anxiety represents an unconscious conflict of needs.
- C. I should confront my spouse when I notice signs of anxiety.
- D. Defense mechanisms increase anxiety.
Correct Answer: B
Rationale: Recognizing anxiety as an unconscious conflict of needs demonstrates understanding of its psychological basis, indicating successful teaching. Other statements are incorrect or promote unhelpful actions like confrontation.