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 B
Explanation
Choice B Reason: Assess for environmental triggers and potential unmet needs.
Choice A Reason:
Consulting the interdisciplinary team regarding behavior modification techniques is important for long-term management of behavioral problems in clients with major neurocognitive disorder. However, it is not the immediate priority when a client is exhibiting acute behavioral escalation. Immediate assessment and intervention are necessary to address the current situation and ensure the client’s safety.
Choice B Reason:
Assessing for environmental triggers and potential unmet needs is the priority in this scenario. Clients with major neurocognitive disorder often exhibit behavioral problems due to unmet needs or environmental factors that they cannot communicate effectively. Identifying and addressing these triggers can help de-escalate the situation and prevent further agitation. This approach aligns with evidence-based practice, which emphasizes understanding the underlying causes of behavioral issues to provide appropriate interventions.
Choice C Reason:
Assessing for potential injury to the client’s arms, legs, and back is crucial, especially if the client is on the ground and exhibiting aggressive behavior. However, this assessment should follow the initial step of identifying and addressing environmental triggers and unmet needs. Ensuring the client’s immediate safety by understanding the cause of their behavior is the first priority.
Choice D Reason:
Anticipating the behavior and physically restraining the client when pacing begins is not recommended as the first line of action. Physical restraint should be a last resort due to the potential for causing harm and increasing the client’s agitation. Instead, non-pharmacological interventions, such as identifying triggers and unmet needs, should be prioritized to manage the behavior safely and effectively.
Correct Answer is A
Explanation
Choice A Reason:
The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.
This is the correct response. Clients with somatoform disorders often experience physical symptoms that cannot be fully explained by any underlying medical condition. However, it is crucial to evaluate any new medical complaints to rule out any actual medical conditions that may require treatment. This approach ensures that the client receives comprehensive care and that any potential medical issues are not overlooked.
Choice B Reason:
The client diagnosed with a somatoform disorder can be easily cured with medication.
This statement is incorrect. Somatoform disorders are complex and often require a multifaceted treatment approach, including psychotherapy, behavioral interventions, and sometimes medication to manage associated symptoms like anxiety or depression. There is no simple cure for somatoform disorders, and treatment typically focuses on managing symptoms and improving the client’s quality of life.
Choice C Reason:
The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.
While clients with somatoform disorders experience real and distressing symptoms, these symptoms are not typically linked to a diagnosable medical condition. The symptoms are believed to be related to psychological factors, and the focus of treatment is often on addressing these underlying psychological issues rather than finding a medical diagnosis.
Choice D Reason:
The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.
This statement is incorrect. Clients with somatoform disorders do not intentionally fake their symptoms. Their symptoms are real to them and cause significant distress and impairment. The symptoms are not under the client’s conscious control, and they genuinely believe they are experiencing a medical condition.
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