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.”

Answer and Explanation

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.

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

Explanation

Choice A reason:

Impaired interpersonal relationships can be a consequence of schizophrenia, but it is not a specific diagnostic criterion in the DSM-5. The criteria focus on more direct symptoms of the disorder.

Choice B reason:

Inability to initiate activities may be related to negative symptoms of schizophrenia, such as avolition, but it is not explicitly listed as a diagnostic criterion in the DSM-5. The criteria include more specific symptoms like disorganized behavior and hallucinations.

Choice C reason:

Disorganized behavior is one of the core symptoms of schizophrenia according to the DSM-5. It includes behaviors that are inappropriate or not goal-directed, reflecting a disruption in normal functioning.

Choice D reason:

Antisocial personality is a separate diagnosis and not a criterion for schizophrenia. Schizophrenia and antisocial personality disorder are distinct conditions with different diagnostic criteria.

Choice E reason:

Hallucinations are a key symptom of schizophrenia. They involve perceiving things that are not present, such as hearing voices or seeing things that others do not see. Hallucinations are one of the primary positive symptoms of schizophrenia.

Choice F reason:

Lack of emotional expression, also known as affective flattening, is a negative symptom of schizophrenia. It involves a reduced ability to express emotions and is a significant criterion in the diagnosis of schizophrenia.

A. “A relapse plan describes how you use coping strategies for living in the community.” B. “A relapse plan addresses your living, housing, and working needs.” C. “A relapse plan explains how you can be hospitalized if needed.” D. “A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse.”

Correct Answer is D

Explanation

Choice A reason:

“A relapse plan describes how you use coping strategies for living in the community.” While this is partially true, it does not fully capture the purpose of a relapse plan. A relapse plan is more comprehensive and includes recognizing early warning signs and taking specific actions to prevent a full relapse.

Choice B reason:

“A relapse plan addresses your living, housing, and working needs.” This statement is not accurate. A relapse plan focuses on managing symptoms and preventing relapse rather than addressing broader social needs like housing and employment.

Choice C reason:

“A relapse plan explains how you can be hospitalized if needed.” While hospitalization may be part of a relapse plan, the primary focus is on recognizing early symptoms and taking steps to manage them before hospitalization becomes necessary.

Choice D reason:

“A relapse plan helps your recovery by recognizing symptoms of schizophrenia and provides steps to follow if symptoms are getting worse.” This statement accurately reflects the purpose of a relapse plan. It emphasizes the importance of early recognition and proactive management of symptoms to support the client’s recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

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

Explanation

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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