A client tells a nurse, "Don't tell anyone but I hid a sharp knife under mymattress in order to

protect myself from my roommate, who is always yelling at me and threatening me." Which

of the following actions shouldthe nurse take?

A. Keep the client's communication confidential, but talk to the clientdaily, using

therapeutic communication to convince him to admit to hiding the knife.

B. Keep the client's communication confidential, but watch the client andhis roommate

closely.

C. Tell the client that this must be reported to the health care teambecause it

concerns the health and safety of the client and others.

D. Report the incident to the health care team, but do not inform theclient of the

intention to do so.

A nurse is caring for a client who is in mechanical restraints. Which of the following

statements should the nurse include in the documentation?(Select all that apply)

A. "Client ate most of his breakfast."

B. "Client was offered 8 oz of water every hr."

C. "Client shouted obscenities at assistive personnel."

D. "Client received chlorpromazine 15 mg by mouth at 1000."

E. "Client acted out after lunch."

A nurse hears a newly licensed nurse discussing a client's hallucinationsin the hallway with

another nurse. Which of the following actions should the nurse take first?

A. Notify the nurse manager.

B. Tell the nurse to stop discussing the behavior.

C. Provide an in-service program about confidentiality.

D. Complete an incident report.

A nurse is caring for the parents of a child who has demonstrated changes in behavior and

mood. When the mother of the child asks thenurse for reassurance about her son's

condition, which of the followingresponses should the nurse make?