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 A

Explanation

A. This comment acknowledges the client's behavior without making assumptions or judgments about the content of the hallucinations. It validates the client's experience and opens the door for further discussion if the client wishes to share more about what they are experiencing.
B. This comment does not directly address the client's current experience and may not be as helpful in validating the client's reality.
C. This comment focuses on redirecting the client's attention rather than acknowledging their experience, which may not be as therapeutic in this context.
D. This comment may invalidate the client's experience by directly contradicting their perception of reality. It is important to avoid dismissing or denying the client's experiences without further assessment and understanding.

A. "The snakes on the wall are going to eat me." B. "The nurse at night is trying to poison me with pills." C. "The voices are telling me to kill the next person I see." D. "The fire is burning my skin away right now." E. None F. None

Correct Answer is B

Explanation

A. "The snakes on the wall are going to eat me." describes a visual hallucination, not a delusion. Hallucinations involve false sensory perceptions, such as seeing things that are not present. While hallucinations are common in schizophrenia, this statement does not indicate a delusion.

B. "The nurse at night is trying to poison me with pills." confirms a delusion, specifically a paranoid delusion. Delusions are fixed, false beliefs that are not based in reality and cannot be changed by logic or reasoning. In this case, the client irrationally believes that the nurse is trying to harm them, which is a classic symptom of schizophrenia.

C. "The voices are telling me to kill the next person I see." describes an auditory hallucination, which involves hearing voices or sounds that are not real. While auditory hallucinations are a common symptom of schizophrenia, this statement does not indicate a delusion.

D. "The fire is burning my skin away right now." describes a tactile hallucination, where the client falsely perceives sensations (e.g., burning). This is another form of hallucination, not a delusion, as it involves sensory misperception rather than a false belief.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

The nurse documents that a client with schizophrenia is delusional. Which statement by the client confirms this assessment?

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.

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

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.

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

A client is admitted to the mental health unit with a bipolar disorder. When seeking to establish a therapeutic relationship and interacting with the client, which comment is best for the nurse to make?