A nurse is planning care for a client who requires close observation. Which of the following rights should the nurse identify that the client has forfeited due to the potential for safety hazards?

The right to parity

The right to make informed decisions

The right to social contact

The right to privacy

Answer and Explanation

The Correct Answer is D

A. The right to parity: Parity refers to the equality or fairness in treatment or access to services. This right ensures that individuals are treated fairly and without discrimination. However, in situations where a client requires close observation due to safety hazards, ensuring parity may not be feasible or appropriate as the primary focus is on preventing harm and promoting safety rather than ensuring equal treatment.

B. The right to make informed decisions: This right emphasizes the client's autonomy and ability to make decisions about their care based on relevant information provided by healthcare professionals. While this right is fundamental in healthcare, in cases where a client poses a risk to their safety or the safety of others due to their condition, such as in cases requiring close observation, the client may temporarily forfeit the right to make informed decisions to ensure their safety.

C. The right to social contact: This right pertains to the client's ability to interact with others and maintain social connections, which are important for emotional well-being. However, in situations where a client requires close observation due to safety concerns, restrictions on social contact may be necessary to prevent harm or injury. For example, if a client exhibits behaviors that pose a risk to themselves or others, limiting social contact can help mitigate these risks and ensure the safety of all individuals involved.

D. The right to privacy: Privacy encompasses the client's right to confidentiality and autonomy over personal matters. However, in situations where a client's safety is at risk and close observation is necessary, the right to privacy may be temporarily forfeited. Close observation often involves continuous monitoring by healthcare providers, which may intrude on the client's privacy. This intrusion is deemed necessary to prevent harm and ensure the client's safety until they are no longer at risk.

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Correct Answer is C

Explanation

A. “Decreased startle response to loud noises.”: Individuals with PTSD often have an exaggerated startle response to loud noises or unexpected stimuli. This heightened startle response is a common symptom of hyperarousal associated with PTSD. Therefore, a decreased startle response would be unexpected in this context.

B. “Reports uninterrupted sleep of 10 to 12 hr each night.”: Sleep disturbances are common among individuals with PTSD. Symptoms can include difficulty falling asleep, staying asleep, or experiencing nightmares related to the traumatic event. Therefore, reports of uninterrupted sleep for 10 to 12 hours each night would be unexpected in someone with PTSD.

C. “Reluctance to discuss the event that precipitated the distress.”: Avoidance of trauma-related thoughts, feelings, or reminders is a hallmark symptom of PTSD. Individuals with PTSD often avoid discussing or thinking about the traumatic event to cope with distressing memories or emotions. Therefore, reluctance to discuss the precipitating event is a common manifestation of PTSD.

D. “Reports feelings of acute distress that began 2 weeks ago.”: PTSD symptoms typically develop shortly after experiencing a traumatic event, but the diagnosis of PTSD requires that symptoms persist for at least one month. Acute distress that began two weeks ago may indicate an acute stress reaction rather than PTSD. PTSD involves persistent symptoms beyond the acute phase of the trauma.

A. A client who has new-onset delirium B. A client who is experiencing auditory hallucinations C. A client who is experiencing mania D. A client who has somatic symptom disorder

Correct Answer is D

Explanation

A. A client who has new-onset delirium: Delirium is characterized by acute confusion and changes in cognition, often due to underlying medical conditions. Assertiveness training may not be appropriate for someone experiencing delirium, as their cognitive impairment may interfere with their ability to participate effectively in the therapy session.

B. A client who is experiencing auditory hallucinations: Auditory hallucinations involve perceiving sounds or voices that are not actually present. Assertiveness training may not directly address the underlying cause of auditory hallucinations, which typically require other therapeutic approaches such as medication management and cognitive-behavioral therapy.

C. A client who is experiencing mania: Mania is a state of elevated mood, increased energy, and often impulsivity. While assertiveness training could potentially be beneficial for individuals with bipolar disorder during periods of stability, it may not be appropriate during acute manic episodes when the client's judgment and insight may be impaired.

D. A client who has somatic symptom disorder: Somatic symptom disorder involves experiencing distressing physical symptoms that are disproportionate to any identified medical condition. Assertiveness training could be helpful for individuals with somatic symptom disorder to effectively communicate their concerns with healthcare providers and advocate for appropriate care.

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A nurse is planning care for a client who requires close observation. Which of the following rights should the nurse identify that the client has forfeited due to the potential for safety hazards?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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