A client states “I have something to tell you in confidence.” Which response by the nurse would be appropriate?
“I don’t want to know this. Tell your health care provider.”.
“I’m your nurse and you can tell me anything.”.
“I’ll close the door first so that no one will hear you.”.
“I can’t promise that the information won’t be shared if your health or safety is involved.”.
The Correct Answer is D
“I can’t promise that the information won’t be shared if your health or safety is involved.” This response by the nurse would be appropriate because it respects the client’s confidentiality while also acknowledging its limits of it. The nurse has a duty to report any information that may indicate a risk of harm to the client or others.
Choice A is wrong because it dismisses the client’s need to share something and implies that the nurse is not interested or trustworthy.
Choice B is wrong because it gives a false assurance of confidentiality and may lead to ethical dilemmas if the client reveals something that requires reporting.
Choice C is wrong because it does not address the issue of confidentiality and may give the impression that the nurse is trying to avoid the conversation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Orthostatic hypotension noted with dangling.
This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.
The nurse should document this finding and report it to the physician.
Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.
Choice B is wrong because the gait belt applied is not a finding but an intervention.
Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.
Choice E is wrong because spot accucheck obtained is not a finding but an action.
Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.
Choice G is wrong because provided reassurance is not a finding but a nursing measure.
Correct Answer is ["A","C","E"]
Explanation
Diazepam is a benzodiazepine that can cause central nervous system depression, which can manifest as decreased blood pressure, impaired physical coordination and respiratory depression. These signs and symptoms are consistent with benzodiazepine intoxication and may require treatment with flumazenil, a benzodiazepine receptor antagonist.
Choice B is wrong because increased temperature is not a sign of benzodiazepine intoxication. Benzodiazepines can cause hypothermia, or low body temperature, due to vasodilation and decreased metabolic rate.
Choice D is wrong because nausea and appetite loss are not signs of benzodiazepine intoxication. Benzodiazepines can cause gastrointestinal effects such as constipation, dry mouth and increased appetite.
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