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,"

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "I think you should calm down a little before you see your partner.":

Explanation: This response might come across as dismissive or insensitive to the partner's feelings. It's important to acknowledge the partner's emotions and offer support rather than suggesting they should calm down.

B. "Do not worry about that. Your wife will be fine.":

Explanation: While it's reassuring to say that the patient will be fine, dismissing the partner's feelings and concerns is not supportive. The partner needs a chance to express their emotions and concerns.

C. "Tell me more about your feelings about what happened to your partner.":

Explanation: Correct Answer. This response is empathetic and encourages the partner to express their emotions. It shows that the nurse is actively listening and is willing to provide a safe space for the partner to share their feelings.

D. "Why do you think the crash is your fault?":

Explanation: This response might come across as accusatory or confrontational, which could exacerbate the partner's feelings of guilt. Instead, the nurse should focus on providing support and understanding.

A. Disclose some personal information to the client to demonstrate approachability. B. Approach the client frequently throughout the day for brief interactions. C. Adopt a neutral attitude when providing care. D. Wait for the client to initiate interaction.

Correct Answer is C

Explanation

Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.

B) Approach the client frequently throughout the day for brief interactions:

While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.

C) Adopt a neutral attitude when providing care.

Explanation:

When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.

D) Wait for the client to initiate interaction:

While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A nurse is Caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

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