During the admission assessment to the mental health unit, a client reports that the people at the office, where the client works, are antagonistic and the client is thinking of shooting the supervisor. The client asks the nurse not to reveal this to anyone else. The nurse immediately notifies the client's therapist and other team members of the client's thoughts. The therapist then calls the client's supervisor and shares the client's thoughts about shooting the supervisor. Which outcome is best based on the action of the nurse?

The nurse is reprimanded for divulging confidential patient information without obtaining informed consent.

Both the nurse and therapist are reprimanded for divulging confidential patient information to others.

The nurse and therapist will be asked to educate other team members on appropriate sharing of client information.

The therapist is reprimanded for divulging confidential patient information without obtaining consent.

Answer and Explanation

The Correct Answer is C

A.   The nurse acted appropriately by disclosing information to the therapist and other team members to ensure the client's safety and well-being. However, educating other team members on appropriate sharing of client information may be necessary to ensure consistency and adherence to privacy laws and ethical guidelines.
B.   Both the nurse and therapist acted in the client's best interest by sharing relevant information with appropriate team members to ensure safety. However, reprimanding them may not be warranted if their actions were based on concerns for the client's safety.
C.   This outcome acknowledges the importance of educating team members on confidentiality and appropriate sharing of client information to maintain trust and privacy while ensuring client safety.
D.   While the therapist did share confidential information with the client's supervisor, it was done in the context of ensuring the safety of all involved parties. Therefore, reprimanding the therapist may not be appropriate in this situation.

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Correct Answer is B

Explanation

Rationale for A: Ineffective sexual patterns would not be the priority as the client's focus on sexual concerns appears to be delusional rather than a reflection of actual sexual dysfunction.

Rationale for B: The client is experiencing delusions, such as an inflated IQ and beliefs about being married to a movie star. These indicate altered perception of reality, making disturbed sensory perception the priority problem to address.

Rationale for C: Compromised family coping could be a concern but is not the primary issue in this situation. The client’s delusions take precedence as they directly impact his mental health and perception of reality.

Rationale for D: Impaired environmental interpretation refers to difficulty understanding the environment, but this client’s issue is more related to delusional thinking rather than misinterpretation of physical surroundings. Therefore, disturbed sensory perception is the more accurate nursing problem.

A. Wait until the client is completely calm B. Ask difficult questions first to get them out of the way C. Use silence as a tool D. Speak with the client in private E. Observe nonverbal behavior and react accordingly F. Ask several questions in a row

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

Explanation

A. Waiting until the client is completely calm is important because it allows the client to feel safe and secure, reducing anxiety and making it easier for them to open up about sensitive issues.
B. Asking difficult questions first is not typically advised as it can increase anxiety and make the client less likely to disclose information. It's important to build rapport and trust before tackling more challenging topics.
C. Using silence as a tool can give the client time to think and process their thoughts, which can lead to more meaningful communication. It also shows the nurse is patient and willing to listen.
D. Speaking with the client in private ensures confidentiality and helps establish a safe space where the client feels comfortable sharing personal information without fear of judgment or exposure.
E. Observing nonverbal behavior and reacting accordingly is crucial as it can provide insights into the client's emotional state and help the nurse respond in a way that is empathetic and supportive.
F. Asking several questions in a row can overwhelm the client and make it difficult for them to provide thoughtful answers. It's better to ask one question at a time and allow the client to fully respond before moving on to the next question.

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Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is B

Explanation

The nurse is caring for a client Exhibits In order to help the client disclose a situation that is upsetting to him, what therapeutic communication tools could the nurse use? Select all that apply.

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

Explanation

The nurse is performing intake interviews at a psychiatric clinic. A client with a known history of drug abuse reports having had a heart attack four years ago. Use of which substance places the client at highest risk for myocardial infarction?

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?

Which individual should the nurse consider at highest risk for suicide?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.