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.”

Answer and Explanation

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.

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Correct Answer is ["B","C","E"]

Explanation

Choice A Reason:

Recommending the client distance themselves from people who knew them before their diagnosis is not a suitable measure for tertiary prevention. Tertiary prevention aims to reduce the impact of an ongoing illness by helping patients manage long-term, complex health problems and injuries. It focuses on improving quality of life and reducing symptoms. Distancing from familiar people could lead to social isolation, which might worsen the client’s condition.

Choice B Reason:

Providing the client with a multi-step written plan to follow if auditory hallucinations occur is a practical measure for tertiary prevention. This plan can help the client manage symptoms effectively and reduce the likelihood of hospitalization. It empowers the client to take control of their symptoms and provides clear steps to follow during a crisis, which can be crucial for maintaining stability.

Choice C Reason:

Risperidone as a depot formulation every 2 weeks is an effective measure for ensuring medication adherence in clients with schizophrenia. Depot formulations are long-acting injections that help maintain consistent medication levels in the body, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients who have difficulty adhering to daily oral medication regimens.

Choice D Reason:

Increasing white bread and bananas to help with anticholinergic symptoms is not a recommended measure for managing schizophrenia. While diet can play a role in overall health, there is no evidence to suggest that these specific foods help with anticholinergic symptoms. Anticholinergic symptoms are typically managed with medications and other medical interventions.

Choice E Reason:

Assisting the client to enroll in a program of assertive community treatment (ACT) is a highly effective measure for tertiary prevention. ACT provides comprehensive, community-based psychiatric treatment, rehabilitation, and support to individuals with serious and persistent mental illnesses. This approach helps clients manage their symptoms, adhere to treatment plans, and reduce the risk of hospitalization by providing continuous, personalized care.

A. Hypertension B. Tinnitus C. Metallic taste D. Dizziness

Correct Answer is D

Explanation

Choice A Reason:

Hypertension.

Hypertension, or high blood pressure, is not a common side effect of lorazepam. Lorazepam is a benzodiazepine, which typically causes sedation and relaxation of muscles, leading to a decrease in blood pressure rather than an increase. Therefore, hypertension is not an expected side effect of this medication.

Choice B Reason:

Tinnitus.

Tinnitus, or ringing in the ears, is also not commonly associated with lorazepam use. While tinnitus can be a side effect of various medications, it is not typically linked to benzodiazepines like lorazepam. Therefore, it is not an expected side effect for clients taking this medication.

Choice C Reason:

Metallic taste.

A metallic taste is not a common side effect of lorazepam. This side effect is more often associated with other medications, such as certain antibiotics or chemotherapy drugs. Lorazepam’s side effects are more related to its sedative properties.

Choice D Reason:

Dizziness.

Dizziness is a common side effect of lorazepam. As a central nervous system depressant, lorazepam can cause drowsiness, dizziness, and lightheadedness. Clients should be advised to avoid activities that require alertness, such as driving, until they know how the medication affects them.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia has had 2 hospitalizations within the past 9 months due to non-adherence to medications and their counseling plan. What measures should the nurse and the mental health treatment team recommend for tertiary prevention? (Select All That Apply)

Correct Answer is ["B","C","E"]

Explanation

The nurse is teaching a client about lorazepam. The nurse should instruct the client to expect which of the following side effects?

Correct Answer is D

Explanation

The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

After being in the hospital for one month, a client with schizophrenia states that voices are telling them they will die tonight. The client asks the nurse if this is true. The client’s statement and question indicate that they:

As the discharge date for a client to leave gets closer, the client states, “I’m afraid to leave here. I’m afraid for my well-being and safety.” Which nursing statement is most supportive?

A client with schizophrenia approaches the nurse with a look of distress and anguish on his face. He says, “Can’t you hear him? It’s the devil. He’s telling me I’m going to hell.” Which is the most appropriate response by the nurse?

A nurse is teaching a class about manual therapies. The nurse should include that which of the following treatments is part of chiropractic medicine?