A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?
“I think that the federal government is spying on me.”
“That doctor I had today really made me angry.”
“I get really ‘turned on’ by your appearance.”
“When I get out of here, I’m going to make my neighbor sorry.”
The Correct Answer is D
Choice A reason:
The statement “I think that the federal government is spying on me” reflects a delusional belief, which is a symptom of certain mental health disorders. While this statement indicates the need for further assessment and possibly treatment, it does not pose an immediate threat to the safety of the client or others. Therefore, it does not warrant breaching confidentiality.
Choice B reason:
Expressing anger towards a doctor, as in the statement “That doctor I had today really made me angry,” is not uncommon in a mental health setting. While it may indicate dissatisfaction or a need for conflict resolution, it does not suggest an immediate risk of harm to the client or others. Confidentiality should be maintained unless there is a clear and imminent threat.
Choice C reason:
The statement “I get really ‘turned on’ by your appearance” is inappropriate and may indicate boundary issues or sexual attraction towards the nurse. While this requires professional handling and possibly setting boundaries, it does not constitute a threat that would necessitate breaching confidentiality.
Choice D reason:
The statement “When I get out of here, I’m going to make my neighbor sorry” indicates a specific threat of harm towards another person. Nurses are legally and ethically obligated to breach confidentiality in situations where there is a clear and imminent risk of harm to the client or others. This duty to warn and protect overrides the obligation to maintain confidentiality.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.
Correct Answer is A
Explanation
Choice A reason:
Feelings are a key component of the psychological domain in the biopsychosocial model. This domain focuses on the client’s emotions, thoughts, and behaviors, which are crucial in understanding and treating mental health problems. Addressing feelings helps the nurse develop a comprehensive care plan that considers the client’s emotional well-being.
Choice B reason:
Cultural groups fall under the social domain of the biopsychosocial model. This domain includes factors such as family, community, and cultural influences on the client’s health. While cultural considerations are important, they are not part of the psychological domain.
Choice C reason:
Family functioning is also part of the social domain. It involves the dynamics and interactions within the client’s family that can impact their mental health. Understanding family functioning is essential, but it is not categorized under the psychological domain.
Choice D reason:
Sleep patterns can be influenced by both psychological and biological factors. However, in the context of the biopsychosocial model, sleep patterns are typically considered part of the biological domain. The psychological domain specifically addresses the client’s emotions and mental processes.
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