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
Choice A reason:
Sitting at the client’s eye level conveys respect and attentiveness. It helps create a sense of equality and openness, making the client feel heard and valued. This positive body language fosters a therapeutic relationship and encourages effective communication.
Choice B reason:
Crossing the arms over the chest can be perceived as defensive or closed-off body language. It may create a barrier between the nurse and the client, hindering open communication and making the client feel unwelcome or judged.
Choice C reason:
Sitting erect with the back against the chair can convey attentiveness and professionalism, but it may also come across as rigid or formal. While it is important to maintain good posture, it is equally important to appear approachable and relaxed.
Choice D reason:
Keeping the feet flat on the floor with the legs crossed can be seen as casual or disengaged body language. It may not convey the same level of attentiveness and respect as sitting at the client’s eye level. Positive body language should make the client feel comfortable and respected.
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.
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