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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The client's belief in having an extraordinarily high IQ and grandiose delusions about being married to a movie star are indicative of disturbed sensory perception.
B. While family coping might be impacted, the primary concern here is the client's altered perception of reality.
C. Impaired environmental interpretation might be related to the delusions but is not the primary problem.
D. Ineffective sexual patterns are not the primary concern in this scenario; the client's altered reality and delusions take precedence.
Correct Answer is D
Explanation
A. "Client has been sexually assaulted" is a formal and concise description. However, it isn’t written as a client would say it which is a key requirement in documentation of the presenting complaint.
B. "Client reported that she had sexual relations against her will" might be accurate but doesn't convey the severity of the situation as clearly as the term "sexually assaulted."
C. "Client claims that she was forced to participate in sexual intercourse" might describe the situation but doesn't necessarily reflect the urgency or trauma of the incident.
D. "Client states, 'My date raped me tonight'" is documented in the client’s own words and is descriptive enough to be the presenting complaint.
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