A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about he desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
"I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
"Because you are a minor, I have to share any information that I feel is important with your parents."
"I cannot promise that. I must share this information with other members of the team who are responsible for planning your care,"
The Correct Answer is D
A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.
B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.
C. "Because you are a minor, I have to share any information that I feel is important with your parents."
While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.
"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."
While it's important to consider the client's preferences, dietary restrictions are often in place for specific health reasons. Trying to incorporate forbidden foods into the diet plan might compromise the client's health and recovery.
B. "Why would you want to put your partner's health at further risk?"
This response is confrontational and may not foster a productive conversation with the partner. It's important to address the situation professionally and collaboratively.
C. "Everyone likes food from home, but it can delay your partner's recovery."
While this response acknowledges the partner's feelings, it's essential to communicate more directly about involving the healthcare provider in decisions about the client's diet.
"D. You will need to discuss your concerns about your partner's diet with the provider."
Explanation: In matters involving a client's dietary plan and health, it's important to involve the healthcare provider to make informed decisions. The nurse should guide the partner to communicate their concerns with the provider who has the authority to evaluate the situation, consider the dietary restrictions, and make a decision that aligns with the client's health and recovery.
Correct Answer is B
Explanation
A) Decreased display of emotions:
While changes in emotional expression can occur in individuals with dementia, it's not a primary manifestation that is typically emphasized when educating families. Behavioral and psychological symptoms, including changes in emotion and personality, can be seen in dementia, but forgetfulness progressing to disorientation is a more direct and characteristic symptom of the condition.
B) Forgetfulness gradually progressing to disorientation
Explanation:
When educating the family of a client with dementia, the nurse should inform them to expect forgetfulness that gradually progresses to disorientation. Dementia is a progressive cognitive decline that affects memory, thinking, and reasoning. Forgetfulness is often one of the initial symptoms of dementia, and as the condition advances, individuals can become disoriented to time, place, and even people. This progression occurs due to the degeneration of brain cells and the accumulation of abnormal proteins.
C) Personality traits that are opposite of original traits:
Changes in personality traits can indeed occur as a result of dementia, but this may not be the most prominent or early manifestation that the nurse would want to highlight when educating the family. The gradual progression of forgetfulness leading to disorientation is a more specific and foundational aspect of dementia.
D) Decreased auditory and visual acuity:
Decreased sensory acuity, such as auditory and visual acuity, can happen with age and various health conditions, but they are not primary manifestations of dementia. Dementia primarily affects cognitive functions like memory, thinking, and reasoning.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today