An adolescent hospitalized after a physical outburst tells the nurse, "I’m going to kill my father, but you can’t tell anyone." Select the nurse’s best response.
You should share this thought with your psychiatrist
I’m concerned about your safety, so I must share this with the team
Let’s discuss why you feel this way
I promise I won’t tell anyone about this
The Correct Answer is B
Choice A reason: Suggesting the adolescent share with the psychiatrist avoids the nurse’s duty to report imminent threats. Ethical and legal standards require immediate action for safety, making this response inadequate, as it delays intervention in a potential crisis.
Choice B reason: Reporting a threat to harm others is a legal and ethical duty in psychiatric nursing, as it indicates imminent danger. Sharing with the team ensures safety interventions, aligning with mandatory reporting laws, making this the correct response.
Choice C reason: Discussing feelings is therapeutic but does not address the immediate safety risk of a threat. Prioritizing exploration over reporting violates ethical standards for managing dangerous behaviors, making this response incorrect in this context.
Choice D reason: Promising confidentiality in the face of a threat violates nursing ethics and legal mandates to report harm risks. This undermines patient and public safety, making it a non-therapeutic and incorrect response to a serious threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Zolpidem, a nonbenzodiazepine sedative, affects the central nervous system, causing sedation and impaired coordination, particularly in the elderly. Age-related declines in metabolism and balance increase fall risk, a critical nursing consideration. Monitoring mobility and ensuring safety measures are essential to prevent injuries, making this the correct choice.
Choice B reason: While zolpidem may cause daytime drowsiness, this is not the primary nursing consideration compared to fall risk in the elderly. Drowsiness is a general side effect, but the elderly’s heightened vulnerability to falls due to sedation and impaired coordination takes precedence, making this choice less critical.
Choice C reason: Zolpidem has a lower dependence risk than benzodiazepines, and dependence is not inevitable. This assumption overstates the risk and is not the primary nursing consideration. Fall prevention, especially in vulnerable populations like the elderly, is more urgent due to immediate safety concerns, making this choice incorrect.
Choice D reason: Zolpidem induces sedation rapidly, typically within 15–30 minutes, not requiring 4 weeks. This choice is factually incorrect, as prolonged use is not necessary for efficacy. The primary concern is immediate side effects like falls, not a delayed onset, making this an invalid nursing consideration.
Correct Answer is A
Explanation
Choice A reason: Basic-level nurses, such as LPNs or RNs, can teach coping skills, a standard intervention within their scope. This involves education on stress management, aligning with psychiatric nursing roles to support patient and family well-being, making this the correct choice.
Choice B reason: Treating major depressive disorder requires advanced skills, like prescribing or managing complex therapies, which is beyond a basic-level nurse’s scope. This is typically reserved for advanced practice nurses or physicians, making this choice incorrect.
Choice C reason: Prescribing antidepressants is restricted to advanced practice nurses or physicians, not basic-level nurses. This task involves medical decision-making outside the scope of RNs or LPNs, making it unsafe and inappropriate, thus incorrect.
Choice D reason: Assessing suicide risk requires advanced clinical judgment, often reserved for advanced practice nurses or psychiatrists. While basic-level nurses can observe and report, formal assessment exceeds their scope, making this choice incorrect for their role.
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