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 ["D"]
Explanation
Older adults do not have a different pain mechanism and do not feel it as much as younger individuals. This statement is false and indicates the need for further education regarding pain management in older adults.
Some possible explanations for the other choices are:
Choice A is true because older adults often fear becoming addicted to pain medications and may underreport or deny their pain.
Choice B is true because older adults often take numerous drugs that can cause interactions with pain medications and increase the risk of adverse effects.
Choice C is true because confusion and delirium can be a more common reaction to certain pain medications in the elderly, especially opioids and benzodiazepines.
Normal ranges for vital signs in older adults are similar to those in younger adults, except for blood pressure, which may be higher due to arterial stiffness. The normal range for blood pressure in older adults is 120/80 to 140/90 mm Hg.
Correct Answer is A
Explanation
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
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