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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.

Answer and Explanation

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.

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Correct Answer is ["C","E"]

Explanation

The correct answer is c, e.

Choice A Reason:

The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.

Choice B Reason:

The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.

Choice C Reason:

The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.

Choice D Reason:

The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.

Choice E Reason:

The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.

A. Use a calm voice. B. Speak louder than the client so as to be heard. C. Reduce stimuli for the client. D. Attempt to redirect the client. E. Reprimand the client for upsetting everyone.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is disoriented to time and place. What additional findings would support a diagnosis of delirium? (Select all that apply.)

Correct Answer is ["C","E"]

Explanation

The nurse is attempting to de-escalate a client who is becoming increasingly agitated on the unit. Which of the following interventions would be appropriate for this type of client? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","D"]

Explanation

The nurse recognizes that a function of the Mental Status Exam is to:

A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

Which action should the nurse take prior to educating clients about relaxation techniques?

The nurse must give 25 micrograms of fentanyl IVP X1 dose. Fentanyl is available in an ampule 100 micrograms per 2m How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

A client with a diagnosis of schizophrenia says to the student nurse, “The mazurkas are coming. The mazurkas are coming.” The client’s use of the word ‘mazurka’ is most likely a/an:

During a morning group meeting, a client raises concern that they cannot sleep at night due to the noises coming from the nurse’s station. The nurse in the meeting interrupts and states, “I’ll handle this matter. Let’s move on.” The nurse is demonstrating which type of leadership style?

The nurse must prepare an oral contrast solution in 850 mL of apple juice. There are 6-ounce containers of apple juice in the pantry. What is the minimum number of containers of juice to make 850 mL? (Round the answer to the nearest whole container)

An IV infusion of 125 mL of a GI prokinetic agent is ordered to be given over 1 hour. The nurse will use a microdrip infusion set (60 gtts/mL). How many drops per minute will the drug infuse at the proper rate? Use a preceding zero if necessary. Do not use trailing zeros.