An adolescent hospitalized after a physical outburst tells the nurse, "I’m going to kill my father, but you can’t tell anyone." Select the nurse’s best response.

You should share this thought with your psychiatrist

I’m concerned about your safety, so I must share this with the team

Let’s discuss why you feel this way

I promise I won’t tell anyone about this

Answer and Explanation

The Correct Answer is B

Choice A reason: Suggesting the adolescent share with the psychiatrist avoids the nurse’s duty to report imminent threats. Ethical and legal standards require immediate action for safety, making this response inadequate, as it delays intervention in a potential crisis.

Choice B reason: Reporting a threat to harm others is a legal and ethical duty in psychiatric nursing, as it indicates imminent danger. Sharing with the team ensures safety interventions, aligning with mandatory reporting laws, making this the correct response.

Choice C reason: Discussing feelings is therapeutic but does not address the immediate safety risk of a threat. Prioritizing exploration over reporting violates ethical standards for managing dangerous behaviors, making this response incorrect in this context.

Choice D reason: Promising confidentiality in the face of a threat violates nursing ethics and legal mandates to report harm risks. This undermines patient and public safety, making it a non-therapeutic and incorrect response to a serious threat.

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Correct Answer is B

Explanation

Choice A reason: Occasional sleeplessness and anxiety are common stress responses and do not necessarily indicate mental illness. These symptoms may reflect temporary issues rather than a diagnosable psychiatric condition, lacking specificity for severe mental illness compared to reality-testing deficits, making this choice incorrect.

Choice B reason: Inability to distinguish reality from non-reality is a hallmark of psychosis, a severe mental illness symptom seen in disorders like schizophrenia. This indicates impaired reality testing, a critical diagnostic criterion, making it the clearest indicator of mental illness among the options, thus the correct choice.

Choice C reason: Uncertainty about job changes reflects normal decision-making stress, not a mental illness. It lacks specificity for psychiatric conditions, as it is a common life concern. This choice does not indicate a significant mental health impairment compared to reality-testing issues, making it incorrect.

Choice D reason: Sadness and low mood may suggest depression, but they are less specific than psychotic symptoms like reality distortion. These feelings can occur in non-clinical contexts, making them less definitive for mental illness compared to inability to discern reality, rendering this choice incorrect.

A. Trust, collaboration, and boundaries B. Medication adherence strategies C. Coping skill development D. Long-term treatment goals

Correct Answer is A

Explanation

Choice A reason: In Peplau’s orientation phase, the nurse establishes trust, fosters collaboration, and sets boundaries to build a therapeutic relationship. This foundation is critical for patients with psychiatric disorders, ensuring a safe space for engagement, making this the correct choice.

Choice B reason: Medication adherence is a clinical intervention addressed later, in the working phase, not orientation. The initial phase focuses on relationship-building, not specific treatments, making this choice incorrect for the orientation phase’s goals.

Choice C reason: Coping skill development occurs in the working phase, after trust is established. Orientation prioritizes relationship foundations like trust and boundaries, not skill-building, making this choice incorrect for the initial nurse-patient interaction phase.

Choice D reason: Long-term goals are addressed in the working or termination phases, not orientation, which focuses on establishing trust and rapport. Setting goals prematurely may hinder relationship-building, making this choice incorrect for the orientation phase.

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An adolescent hospitalized after a physical outburst tells the nurse, "I’m going to kill my father, but you can’t tell anyone." Select the nurse’s best response.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding most clearly indicates that a patient may be experiencing a mental illness?

Correct Answer is B

Explanation

Hildegard Peplau came up with the phases of the nurse-patient relationship. What does the nurse address during the orientation phase with a patient diagnosed with a psychiatric disorder?

Correct Answer is A

Explanation

Which individual diagnosed with a mental illness may require an emergency or involuntary admission?

A nurse is working with a patient diagnosed with schizophrenia who is experiencing auditory hallucinations. Which intervention best supports the patient in managing these symptoms?

Silence can be a helpful therapeutic tool for group participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas. Which statement best supports this?

A patient begins therapy with clozapine medication. What teaching should the nurse provide related to the drug’s strong dopaminergic effect?

A 52-year-old woman says to the nurse, "I should have accomplished more in life, what was I thinking?" Which psychosocial crisis is she experiencing?

In which phase of group therapy should the nurse plan to first address termination?

A patient was hospitalized for 24 hours after a reaction to a psychotropic medication. While planning discharge, the nurse learned the patient received a notice of eviction immediately prior to admission. Select the nurse’s most appropriate action.

A nurse is caring for a patient with a mental health disorder. Which approach best supports therapeutic care?