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
This is because a client who has been diaphoretic for the past six hours is likely to have wet and uncomfortable bed linens that can cause skin breakdown and infection. Changing the bed linens frequently can help keep the client dry and comfortable.
Choice A is wrong because offering the client a bedpan every three hours is not related to diaphoresis.
The client may or may not need to use the bedpan depending on their fluid intake and output.
Choice B is wrong because keeping an emesis basin near the bedside is not related to diaphoresis.
The client may or may not need to vomit depending on their underlying condition.
Choice C is wrong because providing oral care every four hours is not enough for a client who has been diaphoretic for the past six hours. The client may have dry mouth and dehydration due to excessive sweating and may need more frequent oral care and hydration.
Correct Answer is A
Explanation
A 37-year-old who has insulin-dependent diabetes mellitus has the greatest need for special mouth care. This is because diabetes can affect the blood vessels and nerves in the mouth, leading to dry mouth, gum disease, infections, and delayed healing. Special mouth care for this client would include regular brushing and flossing, using a soft toothbrush or foam brush, rinsing with water or saline, checking for signs of inflammation or infection, and avoiding sugary or acidic foods and drinks.
Choice B is wrong because a 58-year-old who wears dentures does not have a greater need for special mouth care than a diabetic client.
Dentures can be removed and cleaned with a soft toothbrush and denture cleaner, and soaked overnight in a denture solution. The gums and mouth should also be cleaned daily with a soft toothbrush or gauze.
Choice C is wrong because a 26-year-old who is on bed rest does not have a greater need for special mouth care than a diabetic client. Bed rest can cause dry mouth and plaque accumulation, but these can be prevented by regular brushing and rinsing, drinking water frequently, and using sugar-free gum or lozenges.
Choice D is wrong because a 45-year-old who is NPO (nothing by mouth) does not have a greater need for special mouth care than a diabetic client. NPO can cause dry mouth and bad breath, but these can be alleviated by regular rinsing with water or saline, applying water-based lip balm or moisturizer, and using artificial saliva products if needed.
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