The phone rings at the nurse's station of an inpatient psychiatric facility. The caller asks to speak with Mr. Hawkins, a client in room 200. Which nursing response protects this client's right to autonomy and confidentiality?

Correct Answer: C

Rationale: The correct answer is C because it respects the client's right to autonomy and confidentiality. By offering to see if Mr. Hawkins wants to talk, the nurse is acknowledging his autonomy to make decisions about who he interacts with. This response also maintains confidentiality by not confirming or denying his presence without his consent. Choice A is incorrect as it does not respect Mr. Hawkins' autonomy and does not offer him the choice to speak with the caller. Choice B is incorrect because it does not protect Mr. Hawkins' confidentiality by potentially revealing his presence. Choice D is incorrect as it does not consider Mr. Hawkins' wishes and simply denies the call without involving him in the decision-making process.

Correct Answer: A

Rationale: The correct answer is A because waving fists, cursing, and shouting threats indicate aggressive and confrontational behavior, which are common signs of a behavioral crisis. This behavior poses a potential threat to others and requires immediate intervention. In contrast, choices B and C show distress or withdrawal, not crisis-level behavior. Choice D depicts an unusual behavior but does not necessarily indicate a crisis. In summary, the correct answer best aligns with the aggressive and threatening behavior typically seen in a behavioral crisis.

Correct Answer: D

Rationale: The correct answer is D (08:00). Lithium blood levels are typically drawn 12 hours after the last dose to ensure accuracy. Since the nurse administered the dose at 8 PM, the blood level should be checked at 8 AM the next day for accurate monitoring and adjustment of the dosage. Option A (22:00) is too soon after administration, option B (00:00) is not 12 hours after administration, and option C (04:00) is also not 12 hours after administration. Therefore, option D is the most appropriate time for obtaining a lithium blood level.

Correct Answer: C

Rationale: The correct answer is C because it respects the client's right to autonomy and confidentiality. By offering to see if Mr. Hawkins wants to talk, the nurse is acknowledging his autonomy to make decisions about who he interacts with. This response also maintains confidentiality by not confirming or denying his presence without his consent. Choice A is incorrect as it does not respect Mr. Hawkins' autonomy and does not offer him the choice to speak with the caller. Choice B is incorrect because it does not protect Mr. Hawkins' confidentiality by potentially revealing his presence. Choice D is incorrect as it does not consider Mr. Hawkins' wishes and simply denies the call without involving him in the decision-making process.

Correct Answer: B

Rationale: The correct answer is B: Aggressive behavior signals. In forensic settings, early recognition of aggressive behavior signals is crucial for preventing potential harm. The nurse and client would focus on identifying triggers, developing coping strategies, and establishing safety plans. This approach aligns with the proactive nature of forensic nursing to prevent escalation of violence. Choices A, C, and D are incorrect because medication side effects, informed consent violations, and discharge needs are important but not directly related to early recognition of potential violence in forensic settings.