A nurse is new to working in mental health nursing. A childhood friend of one of the nurse’s siblings is currently hospitalized as an emergency involuntary admission on an acute locked unit. The nurse texts their sibling that the client is hospitalized and allows the client to use their personal mobile device to video chat with the sibling. It is a policy that clients are not permitted to use personal mobile devices. Which issues should the nurse’s preceptor address? (SELECT ALL THAT APPLY)
It is extremely important to maintain professional boundaries with clients.
Countertransference may have been a factor in your actions with this client.
It would have been better if you called your sibling instead of texting.
Policies can be amended for clients who are admitted voluntarily, not involuntarily.
You have violated HIPAA regulations by notifying your sibling of the client’s admission.
Correct Answer : A,B,E
Choice A Reason:
It is extremely important to maintain professional boundaries with clients.
Maintaining professional boundaries is crucial in nursing to ensure a therapeutic and trusting relationship between the nurse and the client. Crossing these boundaries can lead to ethical issues and compromise the care provided. In this scenario, the nurse allowed personal relationships to influence professional behavior, which is inappropriate and can undermine the client’s trust and the integrity of the nurse-client relationship.
Choice B Reason:
Countertransference may have been a factor in your actions with this client.
Countertransference occurs when a nurse’s personal feelings and experiences influence their professional interactions with a client. In this case, the nurse’s familiarity with the client as a childhood friend of a sibling may have led to biased actions, such as allowing the use of a personal mobile device and sharing confidential information. Recognizing and managing countertransference is essential to maintain objectivity and provide unbiased care.
Choice C Reason:
It would have been better if you called your sibling instead of texting.
This statement is not relevant to the primary issues at hand. Whether the nurse called or texted their sibling does not change the fact that sharing the client’s hospitalization status was a breach of confidentiality. The focus should be on the inappropriate disclosure of protected health information, not the method of communication.
Choice D Reason:
Policies can be amended for clients who are admitted voluntarily, not involuntarily.
This statement is incorrect. Policies regarding the use of personal mobile devices and confidentiality apply to all clients, regardless of whether they are admitted voluntarily or involuntarily. The nurse’s actions violated these policies, and the distinction between voluntary and involuntary admission does not justify the breach.
Choice E Reason:
You have violated HIPAA regulations by notifying your sibling of the client’s admission.
This is the correct response. The nurse violated HIPAA regulations by disclosing the client’s hospitalization status to their sibling without the client’s consent. HIPAA protects the privacy of individuals’ health information, and unauthorized disclosure is a serious violation that can result in legal and professional consequences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Use a calm voice.
Using a calm voice is essential in de-escalating an agitated client. A calm and steady tone can help soothe the client and reduce their anxiety. It also demonstrates that the nurse is in control of the situation and is there to help, which can be reassuring for the client.
Choice B Reason:
Speak louder than the client so as to be heard.
Speaking louder than the client is not appropriate as it can escalate the situation further. Raising one’s voice can be perceived as confrontational and may increase the client’s agitation. It is important to maintain a calm and composed demeanor to help de-escalate the situation.
Choice C Reason:
Reduce stimuli for the client.
Reducing stimuli is an effective intervention for an agitated client. Excessive noise, bright lights, and other environmental stimuli can exacerbate agitation. Creating a quieter and more controlled environment can help the client feel more at ease and reduce their agitation.
Choice D Reason:
Attempt to redirect the client.
Attempting to redirect the client can be helpful in de-escalating agitation. Redirecting the client’s attention to a different topic or activity can help distract them from the source of their agitation and provide a sense of control. This technique can be effective in calming the client and preventing further escalation.
Choice E Reason:
Reprimand the client for upsetting everyone.
Reprimanding the client is not an appropriate intervention. It can increase the client’s feelings of frustration and agitation. Instead, the focus should be on understanding the client’s needs and providing support to help them calm down.
Correct Answer is C
Explanation
Choice A Reason: Have a poor prognosis
A poor prognosis in schizophrenia is typically associated with persistent and severe symptoms, lack of response to treatment, and significant functional impairment. While the client’s statement about hearing voices is concerning, it does not necessarily indicate a poor prognosis on its own. Prognosis in schizophrenia is multifactorial and depends on various factors, including the duration of untreated psychosis, adherence to treatment, and the presence of supportive social networks.
Choice B Reason: Are not improving and may be getting worse
This choice suggests that the client’s condition is deteriorating. While the presence of hallucinations can indicate a lack of improvement, it is important to consider the context. The client’s ability to question the hallucination and seek reassurance from the nurse suggests a level of insight that is often associated with better outcomes. Insight into one’s condition is a positive prognostic factor in schizophrenia.
Choice C Reason: Are questioning the hallucination and want reassurance from the nurse
This is the correct answer. The client’s question indicates that they are aware that the voices might not be real and are seeking reassurance from the nurse. This level of insight is crucial in managing schizophrenia, as it can lead to better adherence to treatment and improved outcomes. Insight into the nature of hallucinations and delusions is often a sign of a more favorable prognosis.
Choice D Reason: Will begin to enter the manic phase of their illness
Mania is characterized by elevated mood, increased activity, and other symptoms such as decreased need for sleep and grandiosity. It is more commonly associated with bipolar disorder than schizophrenia. The client’s statement about hearing voices predicting their death does not align with the typical presentation of mania. Therefore, this choice is not applicable in this context.
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