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","B","E"]
Explanation
Choice A Reason:
The statement “It is okay to eat dessert with my dinner every night” indicates a need for re-teaching. Diet plays a significant role in the risk of developing Alzheimer’s disease. Consuming high amounts of sugar and unhealthy fats can increase the risk of developing conditions like diabetes and cardiovascular disease, which are linked to a higher risk of Alzheimer’s. A balanced diet, such as the Mediterranean or MIND diet, which emphasizes fruits, vegetables, whole grains, and healthy fats, is recommended to reduce the risk.
Choice B Reason:
The statement “I have less to worry about because I am a female” is incorrect and indicates a need for re-teaching. In fact, women are at a higher risk of developing Alzheimer’s disease compared to men. This increased risk is partly due to women living longer than men, but even after accounting for longevity, women still have a higher incidence of Alzheimer’s. Therefore, it is crucial for females to be aware of their risk and take preventive measures.
Choice C Reason:
The statement “I can speak with my healthcare provider about genetic testing” does not indicate a need for re-teaching. Genetic testing can provide valuable information about one’s risk for Alzheimer’s disease, especially if there is a family history of the condition. While routine genetic testing is not generally recommended for everyone, discussing it with a healthcare provider can help individuals understand their risk and make informed decisions about their health.
Choice D Reason:
The statement “I need to make sure to take my blood pressure medication daily” is correct and does not indicate a need for re-teaching. Controlling blood pressure is crucial in reducing the risk of Alzheimer’s disease. High blood pressure, particularly in midlife, is a significant risk factor for cognitive decline and Alzheimer’s. Therefore, taking blood pressure medication as prescribed is an important preventive measure.
Choice E Reason:
The statement “I do not have time in my schedule to add a daily walk” indicates a need for re-teaching. Regular physical activity is one of the most effective ways to reduce the risk of Alzheimer’s disease. Exercise improves blood flow to the brain, reduces inflammation, and promotes the growth of new brain cells. Incorporating physical activity, such as a daily walk, into one’s routine is essential for maintaining cognitive health and reducing the risk of Alzheimer’s.
Correct Answer is ["0.63"]
Explanation
To calculate the correct dose:
- Identify the prescribed dose: 5 mg
- Identify the concentration of the available morphine: 8 mg/mL
- Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL
The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.
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