A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

A client who has borderline personality disorder and acts impulsively

A client who has avoidant personality disorder and becomes anxious in social situations

A client who has dependent personality disorder and clings to nursing staff

A client who has histrionic personality disorder and seeks constant attention

The correct answer is: a) A client who has borderline personality disorder and acts impulsively

Answer and Explanation

The Correct Answer is A

Choice A reason: Clients with borderline personality disorder (BPD) who act impulsively can be a significant safety concern. Impulsive behaviors in BPD can include self-harm, suicidal ideation, substance abuse, and other risky actions. These behaviors can pose immediate and severe threats to the client's safety and require close monitoring, intervention, and support from the healthcare team to manage and mitigate these risks effectively.

Choice B reason: While clients with avoidant personality disorder may experience significant anxiety in social situations, this typically does not pose an immediate threat to their physical safety. The primary concern with avoidant personality disorder is social isolation and the impact on their mental health and quality of life. Anxiety in social situations can be distressing, but it does not inherently lead to dangerous behaviors.

Choice C reason: Clients with dependent personality disorder often exhibit clingy and submissive behaviors, relying heavily on others for support and decision-making. While this can create challenges in managing boundaries and fostering independence, it is not typically associated with immediate safety risks. The focus of care for these clients is on building self-reliance and coping skills.

Choice D reason: Clients with histrionic personality disorder often seek constant attention and may display dramatic, exaggerated behaviors. While this can be disruptive and challenging in a therapeutic setting, it does not usually pose a direct threat to the client's safety. The primary concern is managing interpersonal dynamics and ensuring that the client's behaviors do not negatively impact the therapeutic environment.

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Correct Answer is C

Explanation

Choice A reason: Informing the provider about the conversation might be necessary if there are concerns about confidentiality breaches, but it does not address the immediate issue of discussing private patient information in a public place. The charge nurse's first responsibility is to stop the inappropriate discussion and remind the staff nurse about the importance of maintaining patient privacy.

Choice B reason: While continuing the conversation in a private place is better than discussing it in a public hallway, the staff nurse should not be discussing private patient information unless it is necessary for the patient's care. The charge nurse should emphasize the importance of confidentiality and ensure that such conversations occur only when necessary and in appropriate settings.

Choice C reason: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.

Choice D reason: Telling the staff nurse not to use the client's name in public discussions misses the broader point about confidentiality. Even without using a name, discussing specific details about a patient's condition or admission can still breach their privacy. The charge nurse should emphasize the importance of not discussing patient information in public settings at all.

A. Determine whether the client's goals are met. B. Collect data about the client's current health status. C. Provide the client with information on problem-solving. D. Establish a regular meeting time with the client.

Correct Answer is C

Explanation

Choice A reason: Determining whether the client's goals are met is part of the evaluation phase of the nurse-client relationship. This phase comes after the working phase and focuses on assessing the outcomes of the interventions and the progress made toward achieving the client's goals.

Choice B reason: Collecting data about the client's current health status is typically part of the assessment phase, which occurs at the beginning of the nurse-client relationship. During this phase, the nurse gathers comprehensive information about the client's physical, psychological, and social health to inform the care plan.

Choice C reason: Providing the client with information on problem-solving is an essential component of the working phase of the nurse-client relationship. During this phase, the nurse and client work collaboratively to address issues, develop coping strategies, and implement interventions aimed at improving the client's mental health. Teaching problem-solving skills helps empower the client to manage their condition effectively.

Choice D reason: Establishing a regular meeting time with the client is part of the orientation phase of the nurse-client relationship. In this initial phase, the nurse and client get to know each other, build rapport, and establish the parameters for the relationship, including setting up regular meetings.

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A nurse is collecting data from a group of clients in an acute care mental health facility. For which of the following findings should the nurse be most concerned regarding individual client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says, "I heard that Mr. Smith was admitted for a suicide attempt." Which of the following responses should the charge nurse make?

Correct Answer is C

Explanation

A nurse in a mental health facility is contributing to the plan of care for a new client. Which of the following actions should the nurse plan to include in the working phase of the nurse-client relationship?

Correct Answer is C

Explanation

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