A male client is seeking help in a mental health clinic for anger management problems. He voices that he is fearful that his wife may divorce him because of his anger problem, and he is willing to do “whatever it takes’ to control his anger. Later in the week, the client’s wife also seeks assistance because she is going to divorce her husband.

The nurse who is caring for both of these clients tries to decide the correct action to take. The nurse is experiencing:

An ethical dilemma

Value clarification

A moral conﬂict

A breach of confidentiality

Answer and Explanation

The Correct Answer is A

The nurse is experiencing an ethical dilemma because there are conﬂicting values and ethical principles that need to be considered in this situation. On one hand, the nurse has a duty to maintain the confidentiality of the information shared by each client. On the other hand, the nurse also has a duty to promote the well-being of each client, which may require sharing information between them.

Additionally, there may be issues of autonomy, justice, and beneficence that need to be considered when deciding on the best course of action. It is important for the nurse to carefully consider all of these factors and make a decision that is in the best interest of both clients while upholding ethical principles.

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Correct Answer is C

Explanation

When faced with an unfamiliar treatment instruction, it is important for the nurse to consult the facility’s policies and procedures to determine the appropriate course of action. These policies and procedures provide guidance on how to carry out treatments safely and eﬀectively and can help ensure that the patient receives the best possible care.

While it may also be appropriate for the nurse to call the physician for clarification (a), check the state’s nurse practice act (b), or contact the nursing supervisor for approval (d), consulting the facility’s policies and procedures should be the first step in determining the appropriate course of action.

A. To maintain silence and be attentive to the client’s nonverbal communication and let the client gather his/her thoughts. B. To ask the client a question so the conversation can continue. C. To tell the client that help can be more eﬀective if she shares her feelings. D. To interpret this action as an indication that the client is finished with the conversation.

Correct Answer is A

Explanation

a. To maintain silence and be attentive to the client’s nonverbal communication and let the client gather his/her thoughts.

The best response for the nurse in this situation is to maintain silence and be attentive to the client's nonverbal communication. This allows the client to gather her thoughts and continue the conversation when she is ready. Interrupting the silence with a question or trying to push the client to share her feelings may cause her to withdraw further. It is important for the nurse to respect the client's pace and provide a safe and supportive environment for her to express her thoughts and feelings. Therefore,

Option a is the correct answer.

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Naxlex Comprehensive Predictor Exams

An order written by the physician is reviewed by the nursing staﬀ, and no one is familiar with the treatment instructions. A nurse who is recently hired knows that this treatment is covered by the states nurse practice act. What is the nurses’ best course of action?

Correct Answer is C

Explanation

While the nurse is talking with a female client, the client becomes quiet for several hours. Which is the nurse’s best response?

Correct Answer is A

Explanation

The psychiatrist asks the nurse to perform a procedure that she is not familiar with and the nurse is unsure whether this is something within the scope of practice. Where can the nurse find the answer to this question?

While dining in a restaurant the nurse overhears two co-workers in the next booth discussing a client who is being cared for on the mental health unit which they work. What action have the nurse’s co-workers committed for which they could be held liable for?

A nurse is caring for a young adult client who has ulcerative colitis and is scheduled for surgery to create an ileostomy. After speaking with the provider, the client says, “how will I ever be able to have a normal life after this?” Which of the following responses should the nurse make?

Which question asked by the nurse would gain the most information from a patient experiencing marital crisis?

Nurses who care for patients who are homeless understand that the in the United States:

The following types of patients require adaptive communication techniques: (Select all that apply)

You find a patient on the ﬂoor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the ﬂoor. What is your first step in the nursing process in this situation?