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","C"]

Explanation

A. Suicide is a potential risk following sexual assault due to the emotional trauma that can ensue; however, it is not specific to males and therefore not the best answer in this context.
B. Depression is a common sequela of sexual assault among survivors due to the significant psychological impact of the trauma, which can lead to feelings of sadness, hopelessness, and a loss of interest in activities once enjoyed.
C. Post-traumatic stress disorder (PTSD) is another frequent outcome of sexual assault, characterized by persistent mental and emotional stress as a result of injury or severe psychological shock. PTSD can manifest in nightmares, flashbacks, and severe anxiety, as well as uncontrollable thoughts about the event.
D. Becoming an abuser is a potential outcome for some survivors of sexual assault, but it is not one of the most common sequelae and is not supported by the literature as a primary risk for male survivors.
E. Human immunodeficiency virus (HIV) is a risk in cases of sexual assault where the transmission of bodily fluids occurs, but it is not a psychological sequela and thus not relevant to the question.
F. Chlamydia, like HIV, is a sexually transmitted infection that can be a risk in cases of sexual assault involving transmission of bodily fluids. However, it is not a psychological sequela and is not specific to the male gender in the context of sexual assault risk factors.

A. she only gets 2 to 3 hours of sleep B. She feels that she is "jumpy" after the accident C. I feel so sad that I can't seem to feel anything at all" D. The client has returned to work at an accounting firm

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

Explanation

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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Naxlex Comprehensive Predictor Exams

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

Explanation

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

Explanation

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.