A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

A client who reports that he enjoys smoking marijuana on weekends

A client who reports that she took $20 from the cash register where she works

A client who reports lying to his provider about having suicidal ideation

A client who reports that her partner ties their child to a bed as punishment

Answer and Explanation

The Correct Answer is D

A. A client who reports that he enjoys smoking marijuana on weekends:
This situation involves an individual admitting to recreational drug use. While marijuana use might be illegal in some jurisdictions, it is generally not a reportable offense by itself unless it involves a minor. However, the nurse should educate the client about the potential risks associated with drug use.

B. A client who reports that she took $20 from the cash register where she works:
This scenario involves a confession of theft. While stealing is a legal offense, it does not fall under the category of mandatory reporting unless it involves abuse or neglect of a vulnerable population (such as elderly individuals in a care facility). The appropriate action here would be for the nurse to address the issue within the facility's protocols, but it does not require reporting to an external agency.

C. A client who reports lying to his provider about having suicidal ideation:
This situation involves dishonesty with a healthcare provider. While it is concerning behavior, it does not typically fall under the category of mandatory reporting. Instead, it highlights the importance of addressing trust issues and ensuring open communication between the client and healthcare providers.

D. A client who reports that her partner ties their child to a bed as punishment:
This scenario involves a report of child abuse. Tying a child to a bed as punishment can be considered a form of physical abuse and a violation of the child's safety and well-being. Healthcare professionals, including nurses, are mandated reporters of suspected child abuse or neglect. They are required by law to report such incidents to the appropriate child protective services agency to ensure the safety of the child involved.

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Correct Answer is C

Explanation

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

A. Rambling speech B. Insomnia C. Rapid mood swings D. Sundowning

Correct Answer is B

Explanation

A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.

B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.

C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.

D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.

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A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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