A client tells a nurse, "Don't tell anyone but I hid a sharp knife under my

mattress in order to protect myself from my roommate, who is always

yelling at me and threatening me." Which of the following actions should

the nurse take?

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

daily, using therapeutic communication to convince him to admit to

hiding the knife.

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

his roommate closely.

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

because it concerns the health and safety of the client and others.

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

client 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 hallucinations

in 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 the

nurse for reassurance about her son's condition, which of the following

responses should the nurse make?