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?

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

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

Answer and Explanation

The Correct Answer is B

A.   Both the nurse and therapist took action to ensure safety; therefore, reprimanding might not be appropriate.
B.   The best outcome is an educational approach for the team to understand appropriate information sharing in cases of potential harm to others while maintaining patient confidentiality.
C.   The nurse's immediate notification was based on safety concerns, which may take precedence over obtaining informed consent.
D.   The therapist's action aimed at ensuring safety but might have breached confidentiality without explicit consent.

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Correct Answer is D

Explanation

A. Haloperidol might be used in some detoxification scenarios but isn't directly indicated based on the information provided.
B. Folic acid is not an immediate medication administered during alcohol detoxification.
C. Trazodone is used for other purposes and is not an immediate medication in alcohol detoxification.
D. Vitamin B1 (thiamine) supplementation is crucial during alcohol detoxification to prevent Wernicke-Korsakoff syndrome or other neurological complications associated with
alcohol withdrawal.

A. Ask another nurse to talk with the client. B. Document the client's paranoid behavior. C. Postpone the client interview until the next day. D. Attempt to ask the client simple questions.

Correct Answer is D

Explanation

A. Involving another nurse might not necessarily address the client's guarded and suspicious behavior.
B. Documenting the behavior is important for the client's records, but it doesn't address the immediate need for assessment.
C. Postponing the interview might not resolve the client's guarded behavior and could delay necessary assessment.
D. Attempting to ask the client simple questions allows for a non-threatening approach and might gradually build rapport, encouraging the client to engage in conversation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of alcoholism is admitted for detoxification. Based on treatment protocol, the nurse gives the client a dose of lorazepam 6 mg. Which additional prescription should the nurse administer immediately?

Correct Answer is D

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is D

Explanation

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

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?

Following the visit, what are appropriate actions for the nurse? Select all that apply.

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

A male client tells the nurse that he does not want to take the atypical antipsychotic drug olanzapine because of the side effects he experienced when he took the drug for a year. Which experience is most likely related to taking olanzapine?