The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

Arrange for the client to remain on bedrest.

Tell the client to remain calm.

Encourage the client to share their feelings.

Give the client time to rest and return later for your assessment.

Answer and Explanation

The Correct Answer is C

Choice A reason: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support.

Choice B reason: Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves.

Choice C reason: Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan.

Choice D reason: Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.

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Correct Answer is D

Explanation

Choice A reason: Violation of justice is not a specific legal term used in civil actions. It generally refers to an unfair act or omission but is not applicable to this scenario where specific legal actions are being considered.

Choice B reason: Assault involves creating a fear of imminent harmful or offensive contact. While restraining the client could involve assault, the primary legal issue here is the unlawful confinement of the client.

Choice C reason: Invasion of privacy involves intrusion into someone's personal life without consent. This situation does not relate to privacy invasion but rather to the client's right to freedom and autonomy.

Choice D reason: False imprisonment occurs when someone is confined or restrained against their will without legal justification. The nurse's refusal to restrain the client is appropriate as forcibly restraining a competent client who wishes to leave the hospital would constitute false imprisonment.

A. "Being her friend, you know she is having a difficult time and deserves her privacy." B. "Only because you're worried about a friend, I'll tell you that she is improving." C. "I cannot discuss any client situation with you." D. "If you want to know about Mary, you need to ask her yourself."

Correct Answer is C

Explanation

Choice A reason: This response acknowledges the friend's concern and respects Mary's privacy, but it implies that Mary is indeed having a difficult time, which is a breach of confidentiality. The nurse should not provide any information about the client's situation, even indirectly.

Choice B reason: This response directly shares information about Mary's condition, which is a violation of client confidentiality. The nurse must not disclose any details about a client's health status to someone who is not authorized to receive that information, regardless of their relationship with the client.

Choice C reason: This response is the most appropriate because it clearly states that the nurse cannot discuss any client situation. It respects client confidentiality and adheres to professional and legal standards of privacy.

Choice D reason: While this response directs the neighbor to ask Mary directly, it avoids the issue of confidentiality by not giving any information. However, it is less clear and professional compared to simply stating that the nurse cannot discuss client situations. The response should be straightforward and focused on upholding confidentiality.

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The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

Correct Answer is C

Explanation

A hospital is preparing to receive a large number of casualties from a community disaster. Which clients should the nurse identify as appropriate for discharge?

When planning the delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which element regarding the role of assistive personnel should the nurse consider when delegating tasks?

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Ms. Jones in room 312 doing?" Which response by the nurse would be most appropriate?

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

The nurse educator is educating new staff nurses about mass casualty events. Which statements by the new nurse indicate a need for further teaching? (Select All That Apply)

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?