A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?
“You should share this thought with your psychiatrist.”
“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.”
The Correct Answer is D
Choice A Reason:
“You should share this thought with your psychiatrist.”
This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.
Choice B Reason:
“I can make that promise to you based on nurse-client privilege.”
This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.
Choice C Reason:
“Those kinds of thoughts will make your hospitalization longer.”
This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.
Choice D Reason:
“I cannot promise that. Confidentiality does not include plans to hurt others.”
This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.
This is the correct response. A client’s perception of a stressful event plays a crucial role in determining whether they experience a crisis. If the client views the event as overwhelming and beyond their ability to cope, they are more likely to experience a crisis. Additionally, the availability of social supports, such as family, friends, and community resources, can provide emotional and practical assistance, reducing the likelihood of a crisis. Adequate coping mechanisms, such as problem-solving skills, emotional regulation, and stress management techniques, also play a significant role in helping the client manage stress effectively.
Choice B Reason:
Previous experiences, the availability of medication, and the desire to cope.
While previous experiences can influence how a client responds to stress, they are not the sole determinants of whether a crisis will occur. The availability of medication can help manage symptoms of stress or anxiety, but it does not address the underlying perception of the event or the availability of supports. The desire to cope is important, but without adequate coping mechanisms and support, it may not be sufficient to prevent a crisis.
Choice C Reason:
Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.
Faith in the psychiatrist and the availability of financial resources can provide some support, but they do not directly address the client’s perception of the event or their coping mechanisms. Previous level of functioning is important, but it is not the primary factor in determining whether a crisis will occur. The client’s current perception and available supports are more critical in this context.
Choice D Reason:
The time of day, the client’s mood, and the availability of escape from the situation.
The time of day and the client’s mood can influence their immediate response to stress, but they are not the primary determinants of whether a crisis will occur. The availability of escape from the situation may provide temporary relief, but it does not address the underlying perception of the event or the availability of supports and coping mechanisms.
Correct Answer is B
Explanation
Choice A Reason:
Increase external stimuli.
Increasing external stimuli is not appropriate during a panic attack. Panic attacks are characterized by intense fear and anxiety, often accompanied by physical symptoms such as rapid heartbeat, sweating, and shortness of breath. Increasing external stimuli can exacerbate these symptoms and heighten the client’s distress. The goal during a panic attack is to reduce stimuli and create a calming environment to help the client regain control.
Choice B Reason:
Stay with the client and speak to them in a calm manner.
This is the correct response. Staying with the client and speaking to them in a calm manner provides reassurance and helps to ground them during the panic attack. The presence of a calm and supportive nurse can help reduce the client’s anxiety and provide a sense of safety. This approach aligns with therapeutic communication techniques and is effective in managing acute anxiety episodes.
Choice C Reason:
Allow the client to have their requested space.
While it is important to respect a client’s need for space, leaving them alone during a panic attack may not be the best approach. Clients experiencing panic attacks may feel overwhelmed and frightened, and the presence of a supportive nurse can help them feel safer and more secure. It is important to balance the client’s need for space with the need for support and reassurance.
Choice D Reason:
Review the updated problem list with the client.
Reviewing the updated problem list is not appropriate during a panic attack. This action requires cognitive engagement and focus, which the client may not be capable of during an acute anxiety episode. The priority during a panic attack is to help the client calm down and manage their immediate symptoms, not to discuss or review problems.
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