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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

a. "Focus on the feelings generated by the hallucinations and present reality." This approach validates the child's experience and feelings while gently orienting them to reality, which is a therapeutic communication technique.
b. "Ignore what they are saying, while attempting to discover the underlying cause." Ignoring the child’s statements can make them feel dismissed and could increase their distress. It is important to address their experience directly and compassionately.
c. "Present objective evidence that the voices are not real." Presenting objective evidence may not be effective as the child’s belief in the voices can be very strong, and this approach may lead to further agitation.
d. "Tell them to stop discussing the voices." This approach is dismissive and does not help the child manage their symptoms or feel understood. It is important to engage with the child’s experience constructively.

A. Remain with the client B. Ask the client to describe what was happening before the anxiety began C. Instruct the client to remain alone until the symptoms subside D. Teach the client to recognize signs of a panic attack

Correct Answer is A

Explanation

a. Remain with the client: This is correct because staying with the client provides reassurance and safety, which is crucial during a panic attack.
b. Ask the client to describe what was happening before the anxiety began: While understanding triggers is important, this is not the immediate action during a panic attack when the client needs reassurance.
c. Instruct the client to remain alone until the symptoms subside: This is incorrect as being alone can increase the client’s anxiety and panic.
d. Teach the client to recognize signs of a panic attack: Education is important but should be done after the acute symptoms have subsided. The immediate priority is to provide comfort and safety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Parents ask a nurse how they should reply when their child, diagnosed with schizophrenia disorder, tells them that voices command the child to harm others. Which is the appropriate nursing response?

Correct Answer is A

Explanation

Which of the following would be the best nursing action for a client who is having a panic attack?

Correct Answer is A

Explanation

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