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 ["suicidal ideation"," assessment of risk factors for suicide"]

Explanation

In the context of mental health care, a statement by a client expressing a wish to have died in a traumatic event is indicative of suicidal ideation. This is a serious concern and warrants immediate and careful attention from the healthcare provider. The appropriate response involves conducting a thorough assessment of risk factors for suicide, which may include evaluating the client's mental health history, current stressors, support systems, and any previous suicide attempts or self-harm behavior. This assessment is crucial in determining the level of risk and the need for potential interventions, which may range from close monitoring to emergency psychiatric evaluation. It is essential for healthcare professionals to approach such situations with sensitivity, providing support and ensuring the safety of the client as a priority.

A. "I understand that you're angry and unhappy. Let's explore ways in which you overreact." B. "I hear your frustration about losing control. Tell me how this affects your daily life." C. "Knowing the cause of your symptoms will make them easier to handle." D. "Do all that you can to learn all that you can while you are here. You can get better."

Correct Answer is B

Explanation

A. This comment may come across as invalidating the client's feelings by assuming overreaction, which could potentially escalate the situation.
B. This response acknowledges the client's feelings and invites further exploration, fostering a therapeutic relationship and understanding of the client's experiences.
C. While understanding the cause of symptoms is important, it may not necessarily make them easier to handle, and it could divert focus from addressing the client's immediate concerns.
D. While encouragement is positive, this comment does not directly address the client's feelings or concerns, which is essential for building a therapeutic relationship.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["suicidal ideation"," assessment of risk factors for suicide"]

Explanation

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?

Correct Answer is B

Explanation

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?

The nurse has received a new prescription for the client to begin taking sertraline. Prior to administering the initial dose of sertraline, it is most important for the nurse to obtain which information?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

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

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?

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in depth with the client based on this screening tool?

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?