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 A

Explanation

Choice A reason:
This statement is supportive and realistic. It acknowledges that while complete symptom elimination may not be possible, adherence to the treatment plan can still significantly improve the client’s quality of life. It encourages the client to continue with their treatment in a positive and hopeful manner.

Choice B reason:
This statement is confrontational and may make the client feel defensive. It does not provide support or encouragement and may hinder the therapeutic relationship.

Choice C reason:
This statement is misleading and dismissive. The medical model does not guarantee the elimination of all symptoms, and suggesting the client see another doctor may undermine their confidence in the current treatment plan.

Choice D reason:
This statement is negative and may discourage the client. It implies that the client will not improve and suggests a drastic change without offering hope or support for their current treatment plan.

A. Regression B. Projection C. Repression D. Suppression

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.

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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

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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