A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

Silence

Giving information

Focusing

Broad opening

Answer and Explanation

The Correct Answer is A

Choice A reason: Silence allows the client to process trauma at their own pace, creating a safe, non-pressurized environment. Fearful clients may need time to feel secure before speaking. This technique fosters trust, encourages emotional expression, and is particularly effective in trauma, where verbalization can be challenging due to psychological distress.

Choice B reason: Giving information provides facts but may overwhelm a fearful client, who may not be ready to process details post-trauma. This technique is less effective for engagement, as it does not address emotional barriers or encourage self-expression, which are critical for therapeutic interaction in trauma recovery.

Choice C reason: Focusing directs the conversation to specific topics, which can feel intrusive for a traumatized client. It assumes readiness to discuss, potentially increasing anxiety or withdrawal. This technique is less effective than silence, which allows the client to initiate dialogue when emotionally prepared, fostering trust.

Choice D reason: Broad opening encourages the client to choose topics but may be too vague for a fearful, traumatized client, who may feel overwhelmed by the lack of structure. Silence is more effective, as it provides space for emotional processing without pressuring the client to verbalize prematurely.

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Correct Answer is B

Explanation

Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.

Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.

Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.

Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.

A. Hyperkalemia B. Urine output of 2000 mL in 24 hours C. Tachycardia D. Tenting of the skin

Correct Answer is A

Explanation

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

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A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When is a nurse legally obligated to breach confidentiality?

Correct Answer is B

Explanation

The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The nurse should closely monitor the client for what complication during this phase?

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

The client states, “I understand that in order to leave, I must sign a request to withdraw from treatment.” What is the client’s legal status?

Morphine sulfate 10 mg IV is prescribed. Available 4 mg/mL How many mL be given?

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?