A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?

“I think that the federal government is spying on me.”

“That doctor I had today really made me angry.”

“I get really ‘turned on’ by your appearance.”

“When I get out of here, I’m going to make my neighbor sorry.”

Answer and Explanation

The Correct Answer is D

Choice A reason:
The statement “I think that the federal government is spying on me” reflects a delusional belief, which is a symptom of certain mental health disorders. While this statement indicates the need for further assessment and possibly treatment, it does not pose an immediate threat to the safety of the client or others. Therefore, it does not warrant breaching confidentiality.

Choice B reason:
Expressing anger towards a doctor, as in the statement “That doctor I had today really made me angry,” is not uncommon in a mental health setting. While it may indicate dissatisfaction or a need for conflict resolution, it does not suggest an immediate risk of harm to the client or others. Confidentiality should be maintained unless there is a clear and imminent threat.

Choice C reason:
The statement “I get really ‘turned on’ by your appearance” is inappropriate and may indicate boundary issues or sexual attraction towards the nurse. While this requires professional handling and possibly setting boundaries, it does not constitute a threat that would necessitate breaching confidentiality.

Choice D reason:
The statement “When I get out of here, I’m going to make my neighbor sorry” indicates a specific threat of harm towards another person. Nurses are legally and ethically obligated to breach confidentiality in situations where there is a clear and imminent risk of harm to the client or others. This duty to warn and protect overrides the obligation to maintain confidentiality.

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Correct Answer is C

Explanation

Choice A reason:
Regression involves reverting to an earlier stage of development in response to stress. This defense mechanism is not indicated by Jake’s inability to recall specific details about his mother’s death.
Choice B reason:
Projection involves attributing one’s own unacceptable thoughts, feelings, or flaws to others. This defense mechanism does not explain Jake’s inability to remember details about his mother’s death.
Choice C reason:
Repression is a defense mechanism where distressing memories, thoughts, or feelings are unconsciously pushed out of conscious awareness. Jake’s inability to recall how old he was or the year his mother died suggests that he may be repressing these painful memories.
Choice D reason:
Suppression is a conscious effort to push distressing thoughts or feelings out of awareness. Since Jake is unable to recall specific details, it is more likely that repression, an unconscious process, is at play.

A. PREDICTABLE SOCIAL ENVIRONMENT B. ADEQUATE FOOD C. POSITIVE SELF-IMAGE D. ACCEPTANCE FROM FAMILY

Correct Answer is B

Explanation

Choice A reason:
A predictable social environment is important for providing stability and security, which can contribute to a client’s overall well-being. However, according to Maslow’s hierarchy of needs, physiological needs such as food and water must be met before higher-level needs like social stability can be addressed. Therefore, while important, a predictable social environment is not the immediate priority.
Choice B reason:
Adequate food is a fundamental physiological need according to Maslow’s hierarchy of needs. Physiological needs are the most basic and must be satisfied before an individual can focus on higher-level needs such as safety, love, and self-esteem. Ensuring that the client has adequate food is essential for their survival and overall health, making it the top priority in the plan of care.
Choice C reason:
A positive self-image is associated with self-esteem needs, which are higher up in Maslow’s hierarchy. While fostering a positive self-image is important for a client’s mental health and well-being, it cannot be effectively addressed until basic physiological needs are met. Therefore, it is not the immediate priority in the plan of care.
Choice D reason:
Acceptance from family relates to the need for love and belonging, which is also higher up in Maslow’s hierarchy. While family acceptance is crucial for emotional support and social well-being, it is not as immediate a priority as ensuring that the client’s basic physiological needs, such as adequate food, are met first.

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A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

Correct Answer is B

Explanation

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