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","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.

A. A Social withdrawal B. B Exaggerated startle response C. C Intrusive thoughts D. D Avoidance of places associated with the assault

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

Explanation

Social withdrawal: This is a common symptom as individuals may avoid social interactions and isolate themselves due to ongoing distress.
Prepared by Brandel
B) Exaggerated startle response: Individuals may have an increased startle reflex following trauma, which can persist over time.
C) Intrusive thoughts: These are unwanted and distressing thoughts related to the trauma that can continue to affect the individual.
D) Avoidance of places associated with the assault: This behavior is a protective mechanism to prevent re-experiencing the traumatic event.
E) Overeating: Overeating is not a characteristic sequalae of rape trauma. F) Hallucinations: Hallucinations are not typically associated with long-term symptoms of rape trauma syndrome. Hallucinations can occur in severe cases, particularly if there are co-occurring mental health disorders such as PTSD.

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Naxlex Comprehensive Predictor Exams

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

Explanation

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

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

Explanation

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

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?

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 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.

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?