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:
Admission to a locked inpatient psychiatric unit is a more restrictive environment. While necessary for some clients, it limits their freedom and autonomy. The least restrictive environment principle seeks to avoid such settings unless absolutely necessary.

Choice B reason:
Placement in a secured padded room is highly restrictive and typically used only in extreme cases where the client poses an immediate danger to themselves or others. This setting is far from the least restrictive environment.

Choice C reason:
Involuntary commitment to an outpatient community mental health center represents a less restrictive environment. It allows the client to receive necessary treatment and support while remaining in the community, maintaining a higher level of independence and normalcy.

Choice D reason:
Medication administration for sedation to the point where the client cannot get out of bed is a highly restrictive intervention. It significantly limits the client’s autonomy and is not aligned with the principle of providing care in the least restrictive environment.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

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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

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

Correct Answer is C

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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