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 D

Explanation

a. "Why are you concerned about these types of questions?"
This response can seem confrontational and might increase the client's defensiveness.
b. "We can skip these questions, if you like. It isn't imperative that we complete this section."
Skipping the questions can lead to an incomplete assessment, and it does not address the client's concern.
c. "It is just a routine part of our assessment. All clients are asked these same questions."
While this is true, it does not explain the importance of the questions and may seem dismissive.
d. "Psychological factors like excessive stress have been found to affect medical conditions."
This response explains the rationale behind the questions and how they relate to the client's overall health, potentially helping the client understand the importance of a holistic assessment.

A. The unit can be managed with fewer staff B. Clients are encouraged to communicate with others C. The reduced sensory input allows the client to regain control D. Clients are forced to be responsible for themselves

Correct Answer is C

Explanation

a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.

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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

During a client intake assessment, the nurse asks both physiological and psychosocial questions. The client angrily responds, "I'm here for my heart, not my head problems." What is the nurse's best response?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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