A nurse is caring for a client who asks the nurse, “May I please have your home address so that I can send you a note after I get home?” Which of the following responses should the nurse give?
“I know you are looking forward to being at home again and having a normal routine.”
“Sure, I will write it down for you.”
“Absolutely not! We are not allowed to give out our personal information!”
“Thank you for your kind words. Unfortunately, I am not allowed to share my home address by policy of the hospital.”
The Correct Answer is D
Choice A reason: Acknowledging the client’s excitement avoids the request but doesn’t address boundaries. A clear, professional response about policy maintains trust and safety, making this less effective and incorrect.
Choice B reason: Giving a personal address violates professional boundaries and safety policies. Nurses must maintain privacy, and sharing personal information is inappropriate, making this incorrect and risky.
Choice C reason: A harsh refusal damages therapeutic rapport. While correct about policy, the tone is unprofessional and may alienate the client, making this less appropriate than a polite explanation.
Choice D reason: Politely declining due to hospital policy maintains professionalism and boundaries while appreciating the client’s intent. This fosters trust and adheres to ethical standards, making it the correct response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Confusion and agitation occur in Huntington’s, but “loss of motor abilities” is vague. Excessive movements (chorea) are specific, making this less accurate than the correct choice.
Choice B reason: Huntington’s disease causes mental deterioration, mood swings, and excessive movements (chorea). These are hallmark symptoms reflecting neurological degeneration, making this the correct clinical manifestation set.
Choice C reason: Euphoria and flaccidity are not typical of Huntington’s; depression and chorea are. Cognitive decline occurs, but the other symptoms don’t fit, making this incorrect.
Choice D reason: Spasticity is not a Huntington’s feature; chorea is. Emotional disturbances and incontinence occur, but excessive movements are more specific, making this incorrect.
Correct Answer is A
Explanation
Choice A reason: Asking if the client has a suicide plan is the priority, as it assesses the immediacy and specificity of suicidal intent, critical in depression due to serotonin and norepinephrine dysregulation. A specific plan indicates high risk, necessitating immediate safety measures to prevent self-harm driven by impaired emotional regulation.
Choice B reason: Notifying family and requesting a visitor may provide support but does not immediately assess the client’s suicide risk. Depression-related suicidal ideation, linked to prefrontal cortex dysfunction, requires direct evaluation of intent and plan to ensure safety, making this a secondary action after risk assessment.
Choice C reason: Assisting the client to rest in her room dismisses the suicidal statement, risking neglect of a serious threat. Depression’s neurochemical imbalances can amplify hopelessness, and ignoring suicidal ideation may escalate risk, as it fails to address the immediate need for safety and intervention.
Choice D reason: Recognizing the statement as manipulation is inappropriate, as it dismisses genuine suicidal ideation in depression, driven by profound neurochemical despair. This risks underestimating the client’s intent, potentially leading to harm, as suicidal thoughts require serious assessment rather than being attributed to behavioral manipulation.
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