A client asks the nurse to promise to keep confidential a plan the client has to kill their father. Which of the following statements would be the best response for the nurse to make?
"I can make that promise to you based on nurse-client privilege."
"Those kinds of thoughts will make your hospitalization longer."
"I cannot promise that. Confidentiality does not include plans to hurt others."
"You should share this thought with your psychiatrist."
The Correct Answer is C
a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Remain with the client: This is correct because staying with the client provides reassurance and safety, which is crucial during a panic attack.
b. Ask the client to describe what was happening before the anxiety began: While understanding triggers is important, this is not the immediate action during a panic attack when the client needs reassurance.
c. Instruct the client to remain alone until the symptoms subside: This is incorrect as being alone can increase the client’s anxiety and panic.
d. Teach the client to recognize signs of a panic attack: Education is important but should be done after the acute symptoms have subsided. The immediate priority is to provide comfort and safety.
Correct Answer is B
Explanation
a. Excessive time spent discussing psychosocial stressors: Somatic Symptom Disorder focuses on physical symptoms, not necessarily psychological factors.
b. Disproportionate and persistent thoughts about the seriousness of one's symptoms: This is a hallmark symptom of Somatic Symptom Disorder. The client is likely preoccupied with their health beyond what's medically warranted.
c. Amnestic episodes in which the client is pain free: Amnesia is not a characteristic symptom of Somatic Symptom Disorder.
d. Lack of physical symptoms: Somatic Symptom Disorder by definition involves physical symptoms, even if they are not medically explained.
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