A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

“I need to make sure that the potential victim is warned."

"I need to keep the information confidential due to the client's right to privacy."

“I can only discuss the client's threats with a court order."

"I should verbally report this information to the psychiatrist."

Answer and Explanation

The Correct Answer is A

A. "I need to make sure that the potential victim is warned."

Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.

B. "I need to keep the information confidential due to the client's right to privacy."

Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

C. "I can only discuss the client's threats with a court order."

Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

D. "I should verbally report this information to the psychiatrist."

Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.

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Correct Answer is B

Explanation

While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.

B. Decrease anxiety to a tolerable level.

Explanation: Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.

C. Manipulate and control others' behaviors.

The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.

D. Limit the amount of time available to interact with others.

The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.

A. Provide an activity schedule that changes from day to day. B. Rotate assignment of daily caregivers. C. Limit time for the client to perform activities. D. Talk the client through tasks one step at a time

Correct Answer is D

Explanation

A. Providing an activity schedule that changes from day to day might be overwhelming and confusing for a client with Alzheimer's disease, as routine and predictability are often more beneficial.

B. Constantly rotating caregivers can lead to increased confusion for the client, as familiarity and consistency are important in their care.

C. Limiting time for the client to perform activities can add unnecessary stress and may not be conducive to a comfortable and supportive environment for someone with Alzheimer's disease.

D. Talk the client through tasks one step at a time.

For a client with Alzheimer's disease, providing clear and simple instructions is crucial. Breaking tasks down into manageable steps helps the client follow and complete activities more effectively. This approach reduces confusion and frustration and promotes the client's ability to engage in activities of daily living.

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A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

Correct Answer is B

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment?

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings are risk factors of depression? (Select all that apply.)

A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates understanding of the teaching?

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse's station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?