Extract:

Question 1 of 5

One evening the client takes the nurse aside and whispers, 'Don't tell anybody, but I'm going to call in a bomb threat to this hospital tonight.' Which of the following actions is the priority?

Correct Answer: D

Rationale: Explaining that the information must be shared immediately prioritizes safety, as the threat poses a serious risk to the hospital, requiring prompt reporting to ensure protection.

Question 2 of 5

In which of the following situations can a client's confidentiality be breached legally?

A. To answer a request from a client's spouse about the client's medication. B. In a student nurse's clinical paper about a client. C. When a client near discharge is threatening to harm an ex-partner. D. When a client's employer requests the client's diagnosis to initiate medical claims.

Correct Answer: C

Rationale: Confidentiality can be breached legally when there is a duty to warn, such as when a client threatens harm to others, as this prioritizes public safety. Sharing with a spouse, in a student paper, or with an employer violates confidentiality unless specific consent is given.

Question 3 of 5

The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which of the following statements by the mother indicates that she understands her daughter's illness and management?

A. I know that I'll have to do everything for my daughter when she comes home.' B. Tasks as simple as getting out of bed and showering in the morning may be difficult for her.' C. I know that visits from her friends at home should be discouraged for a while.' D. She won't experience a relapse as long as she takes her prescribed medication.'

Correct Answer: B

Rationale: Understanding that basic tasks like getting out of bed and showering may be challenging reflects accurate knowledge of the negative symptoms of schizophrenia and their impact on daily functioning.

Question 4 of 5

A client is being discharged after 3 days of hospitalization for a suicide attempt that followed the loss of a job. Which of the following should be the nurse's priority action before discharge?

A. Increase the client's antidepressant dosage. B. Provide a list of community support groups. C. Ensure the client has a follow-up appointment with a mental health provider. D. Instruct the client to avoid all work-related activities for a month.

Correct Answer: C

Rationale: Ensuring a follow-up appointment with a mental health provider is the priority to maintain continuity of care and monitor the client's suicide risk post-discharge. Increasing medication requires a physician's order and careful evaluation, community support groups are secondary, and avoiding work activities is unrealistic and not directly tied to immediate safety.

Question 5 of 5

The nursing assistant states to the nurse, 'My client talks about how awful and useless she is. Sometimes she sounds angry for no reason. I'm tired of listening to her.' Which of the following responses by the nurse is most appropriate?

A. I'll switch your assignment to someone who's less depressed and less tiring.' B. It's important for you to listen to her because she needs to verbalize how she is feeling.' C. Don't worry about it. I know you haven't done anything to make her angry.' D. Clients with depression are hard to deal with, but don't take what they say seriously.'

Correct Answer: B

Rationale: Listening to the client's feelings is therapeutic and supports emotional expression.