While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

Provide the client with a written hospital policy regarding privacy of information laws.

Tell the client that confidentiality will be maintained, except when one’s safety is threatened.

Nod in the affirmative, but make no verbal commitment to the client.

Assure the client that information provided will be shared with the staff only.

Answer and Explanation

The Correct Answer is B

A.   Providing the client with written information about privacy laws is a good practice, but a verbal explanation is also necessary to address the immediate concern.
B.   This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk.
C. Non-verbal gestures may be ambiguous and could lead to misunderstandings. It's important to communicate clearly with the client.
D.   Assuring the client that information will be shared only with the staff may not be entirely accurate, as there are situations where confidentiality must be breached, such as when safety is a concern.

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Correct Answer is A

Explanation

A. Feeling angry, embarrassed, and helpless may indicate subconscious blame or judgment toward the client for staying in an abusive relationship. It's important for the nurse to recognize and address these feelings to provide non-judgmental and supportive care.
B. Difficulty accepting the explanation about how the injuries occurred could contribute to these feelings, but it is not the primary cause in this context.
C. Limited experience in caring for clients affected by family violence may contribute to discomfort, but it does not explain the specific emotions described.
D. While a personal history of abuse could impact the nurse's feelings, the question is asking for the immediate cause of the emotions during the current interaction with the client.

A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever. B. Place the client in protective isolation for the first two weeks of treatment with this medication. C. Offer this medication to the client with food to decrease the possibility of gastric upset. D. Report findings from the client’s weekly white blood cell (WBC) counts to the healthcare provider.

Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

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While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been the victim of intimate partner violence. During the interview, the nurse feels angry, embarrassed, and helpless. Which explanation best describes the cause of the nurse’s emotions?

Correct Answer is A

Explanation

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

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A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?