A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?

“You should share this thought with your psychiatrist.”

“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.”

Answer and Explanation

The Correct Answer is D

Choice A Reason:

“You should share this thought with your psychiatrist.”

This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B Reason:

“I can make that promise to you based on nurse-client privilege.”

This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C Reason:

“Those kinds of thoughts will make your hospitalization longer.”

This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D Reason:

“I cannot promise that. Confidentiality does not include plans to hurt others.”

This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.

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Correct Answer is A

Explanation

Choice A Reason:

The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.

This is the correct response. Clients with somatoform disorders often experience physical symptoms that cannot be fully explained by any underlying medical condition. However, it is crucial to evaluate any new medical complaints to rule out any actual medical conditions that may require treatment. This approach ensures that the client receives comprehensive care and that any potential medical issues are not overlooked.

Choice B Reason:

The client diagnosed with a somatoform disorder can be easily cured with medication.

This statement is incorrect. Somatoform disorders are complex and often require a multifaceted treatment approach, including psychotherapy, behavioral interventions, and sometimes medication to manage associated symptoms like anxiety or depression. There is no simple cure for somatoform disorders, and treatment typically focuses on managing symptoms and improving the client’s quality of life.

Choice C Reason:

The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.

While clients with somatoform disorders experience real and distressing symptoms, these symptoms are not typically linked to a diagnosable medical condition. The symptoms are believed to be related to psychological factors, and the focus of treatment is often on addressing these underlying psychological issues rather than finding a medical diagnosis.

Choice D Reason:

The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.

This statement is incorrect. Clients with somatoform disorders do not intentionally fake their symptoms. Their symptoms are real to them and cause significant distress and impairment. The symptoms are not under the client’s conscious control, and they genuinely believe they are experiencing a medical condition.

A. Clear and organized speech B. Increased attention and focus C. Fluctuating levels of consciousness D. Stable and consistent cognitive function E. Agitation and aggression

Correct Answer is ["C","E"]

Explanation

The correct answer is c, e.

Choice A Reason:

The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.

Choice B Reason:

The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.

Choice C Reason:

The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.

Choice D Reason:

The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.

Choice E Reason:

The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.

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A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?

Correct Answer is A

Explanation

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who is diagnosed with Functional Neurologic Symptom Disorder (conversion disorder). What action should the nurse include in the plan of care?

A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.

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Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

An inpatient client who has a known history of violence suddenly begins to pace. Which additional client behavior should alert the nurse to escalating anger and aggression? The client:

The client hears the word “match.” The client replies, “A match is a catch. A catch is a batch. The batch started to hatch.” Which communication pattern does the nurse identify?

The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?