A client asks the nurse to promise to keep confidential a plan the client has to kill their father. Which of the following statements would be the best response for the nurse to make?
"I can make that promise to you based on nurse-client privilege."
"Those kinds of thoughts will make your hospitalization longer."
"I cannot promise that. Confidentiality does not include plans to hurt others."
"You should share this thought with your psychiatrist."
The Correct Answer is C
a. "I can make that promise to you based on nurse-client privilege." Nurse-client confidentiality is important, but it doesn't apply to threats of violence. The nurse has a duty to protect the client and others.
b. "Those kinds of thoughts will make your hospitalization longer." While true, this response doesn't directly address the safety concern and might be perceived as judgmental.
c. "I cannot promise that. Confidentiality does not include plans to hurt others." This is a clear and honest statement. It explains the limitations of confidentiality and prioritizes safety.
d. "You should share this thought with your psychiatrist." While encouraging the client to talk to a psychiatrist is a good suggestion, it doesn't directly address the confidentiality issue or the immediate threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Muscle rigidity and stiffness: This is correct because muscle rigidity and stiffness are signs of extrapyramidal symptoms (EPS), which benztropine is prescribed to treat.
b. Constipation and dry mouth: These are common side effects of antipsychotics but do not warrant benztropine, which is specifically used to manage EPS.
c. Tachycardia and hypotension: These are not related to the EPS that benztropine treats. They may require other interventions.
d. Reports of photosensitivity: Photosensitivity is not related to EPS and does not require benztropine.
Correct Answer is C
Explanation
a. "Where do you buy your food?" While this provides information about food access, it doesn’t directly assess nutritional intake.
b. "Does someone else prepare your meals?" This might provide insight into the client's independence, but it doesn't directly assess nutritional intake.
c. "Tell me what you eat in a typical day." This directly assesses the client’s dietary intake and provides a comprehensive view of their nutrition status.
d. "Are you taking any medications that change your taste of foods?" This is relevant but more specific to one aspect of dietary intake. It does not provide a full picture of the client’s nutritional status like option c.
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