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:
Ask the client direct questions about the hallucinations.
This response is the most appropriate because it allows the nurse to assess the content and nature of the hallucinations directly. By understanding what the client is experiencing, the nurse can better evaluate the risk of harm to the client or others and develop an appropriate care plan. Direct questioning helps in identifying whether the hallucinations are commanding the client to perform harmful actions, which is crucial for ensuring safety. This approach aligns with therapeutic communication techniques that emphasize understanding the client’s experience and providing appropriate interventions.
Choice B Reason:
Act as if the hallucinations are real.
This response is not appropriate because it can reinforce the client’s delusions and hallucinations, making it harder for them to distinguish between reality and their hallucinations. It is important for the nurse to maintain a reality-based approach while being empathetic and supportive. Acknowledging the client’s feelings without validating the hallucinations helps in maintaining a therapeutic environment.
Choice C Reason:
Instruct the client to argue with the voices.
Instructing the client to argue with the voices is not recommended as it can increase the client’s distress and confusion. Instead, the nurse should help the client develop coping strategies to manage the hallucinations, such as distraction techniques or reality testing. Encouraging the client to engage in a confrontation with their hallucinations can exacerbate their symptoms and is not a therapeutic approach.
Choice D Reason:
Explain to the client that the hallucinations will subside soon.
This response is not appropriate because it provides false reassurance. Hallucinations may not subside quickly, and the client needs realistic support and coping strategies to manage their symptoms. Providing false hope can undermine the client’s trust in the nurse and the treatment process. Instead, the nurse should focus on helping the client manage their symptoms effectively.
Correct Answer is ["A","C","E"]
Explanation
Choice A Reason:
Restating involves repeating what the client has said in order to show understanding and to encourage them to continue talking. This technique helps to clarify the client’s thoughts and feelings, ensuring that the nurse accurately understands the client’s message. It also demonstrates active listening and empathy, which are crucial components of therapeutic communication.
Choice B Reason:
Giving advice is generally considered a non-therapeutic communication technique. It can imply that the nurse knows best and can undermine the client’s autonomy and decision-making abilities. Instead of giving advice, therapeutic communication focuses on helping clients explore their own thoughts and feelings to arrive at their own conclusions and solutions.
Choice C Reason:
Maintaining neutral responses involves responding to the client in a way that does not convey judgment or bias. This technique helps to create a safe and supportive environment where the client feels comfortable sharing their thoughts and feelings. Neutral responses can include nodding, making non-committal sounds like “mm-hmm,” and using phrases like “I see” or “Tell me more”.
Choice D Reason:
Asking the client “Why?” can be perceived as confrontational or judgmental, which can hinder open communication. It may make the client feel defensive or uncomfortable. Instead, therapeutic communication techniques involve asking open-ended questions that encourage the client to express themselves without feeling judged.
Choice E Reason:
Listening is one of the most fundamental therapeutic communication techniques. It involves giving the client your full attention, showing interest in what they are saying, and responding appropriately to their concerns. Active listening helps to build trust and rapport, making the client feel heard and understood.
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