The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

Apologize for asking such a personal and intrusive question

Encourage the client to make a list of their concerns and offer to discuss it with them on how to cope with homelessness

Divert the subject to something the client will readily discuss

Sit quietly allowing the client time to process before responding

Answer and Explanation

The Correct Answer is D

Choice A reason: Apologizing for the question may imply it was inappropriate, undermining the therapeutic intent to explore emotions. Homelessness is a valid topic in mental health care, and apologizing could discourage further discussion, disrupting trust and the client’s ability to process and express difficult emotions.

Choice B reason: Encouraging a list of concerns shifts focus to problem-solving prematurely, potentially overwhelming the client who is processing emotions. This action disregards the client’s need for reflection, which is critical in therapeutic communication to facilitate emotional expression and address underlying psychological distress effectively.

Choice C reason: Diverting the subject avoids the client’s emotional response, missing a therapeutic opportunity to explore feelings about homelessness. This can signal discomfort with the topic, reducing trust and hindering the client’s ability to process trauma, which is essential for mental health recovery and coping.

Choice D reason: Sitting quietly allows the client time to process complex emotions about homelessness, fostering a safe therapeutic environment. Silence supports reflection, enabling the client to articulate feelings at their pace, which enhances trust and facilitates deeper emotional exploration, making it the most therapeutic response in this context.

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Correct Answer is C

Explanation

Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.

Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.

Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.

Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.

A. When the client violates the nurse’s boundaries B. If threats are made to an identifiable third party C. Whenever the client becomes aggressive D. At any time a client does not agree with the nurse

Correct Answer is B

Explanation

Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.

Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.

Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.

Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.

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The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

Correct Answer is C

Explanation

When is a nurse legally obligated to breach confidentiality?

Correct Answer is B

Explanation

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

Which statement about nonverbal communication is accurate?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

A client diagnosed with chronic kidney disease is completing an exchange during peritoneal dialysis. The nurse observes that the peritoneal fluid is draining slowly and that the client’s abdomen is increasing in girth. What is the nurse’s most appropriate action?

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?