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 B

Explanation

Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.

Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.

Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.

Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.

A. Sitting at the client’s eye level B. Crossing the arms over the chest C. Sitting erect with back against the chair D. Keeping the feet flat on the floor with the legs crossed

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.

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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

The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

Correct Answer is B

Explanation

When communicating with a client, which would a nurse use to convey positive body language?

Correct Answer is A

Explanation

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