A client with paranoid schizophrenia believes evil spirits are being summoned by a local minister and verbally threatens to bomb a local church.
The psychiatric nurse notifies the local minister.
The psychiatric nurse has:
Released the client's information without proper authorization.
Avoided charges of malpractice.
Demonstrated the duty to warn and protect.
Violated the patient's privacy and confidentiality.
The Correct Answer is C
Choice A rationale:
While it's true that the nurse has released the client's information without their explicit consent, this action is justified under the duty to warn and protect.
This duty supersedes the general obligation to maintain confidentiality when there's a serious and imminent threat to identifiable individuals or the public.
In this case, the client's verbal threat to bomb a local church constitutes a credible and foreseeable risk of harm, necessitating the breach of confidentiality to protect potential victims.
Choice B rationale:
Although the nurse's actions may help to avoid malpractice charges by demonstrating responsible care and adherence to ethical obligations, this is not the primary reason for notifying the minister.
The primary goal is to avert harm and fulfill the duty to warn, not to shield oneself from legal liability.
Choice C rationale:
This is the correct answer. The nurse has acted in accordance with the duty to warn and protect, which is a legal and ethical obligation in healthcare.
This duty mandates that healthcare professionals take reasonable steps to warn potential victims and protect the public when a patient communicates a serious threat of harm.
Choice D rationale:
While confidentiality is a cornerstone of healthcare ethics, it's not absolute.
The duty to warn and protect allows for limited breaches of confidentiality when necessary to prevent serious harm, as in this case.
The nurse's actions align with ethical principles and legal requirements, even though they involve disclosing confidential information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The correct answer is choiceAandE.
Choice A rationale:
Monitoring the client’s weight daily is crucial in managing anorexia nervosa.It helps track the client’s progress and ensures that any significant weight changes are promptly addressed.
Choice B rationale:
Allowing the client to choose their meals can be counterproductive.Clients with anorexia nervosa may make choices that do not support their nutritional needs, potentially exacerbating their condition.
Choice C rationale:
Allowing the client to practice strenuous exercises is not advisable.Strenuous exercise can further deplete the client’s already low energy reserves and exacerbate malnutrition.
Choice D rationale:
Staying with the client during meals and for 2 hours after meals is incorrect.The recommended practice is to stay with the client for 30 minutes after meals to monitor for any purging behaviors.
Choice E rationale:
Providing the client with small meals frequently is beneficial. It helps in managing their nutritional intake without overwhelming them, which can be more acceptable and manageable for clients with anorexia nervosa.
Correct Answer is B
Explanation
Choice A rationale:
Planning a therapeutic diet for the client is not the first priority. While a therapeutic diet may be necessary at some point, it is important to first assess the client's nutritional status to determine their individual needs. A diet plan that is not tailored to the client's specific needs could be ineffective or even harmful.
Focusing on diet planning prematurely could also reinforce the client's distorted body image and eating disorder behaviors. It is important to address the underlying psychological issues before implementing dietary interventions.
Choice C rationale:
Requesting a mental health consult is important, but it is not the first priority. The nurse should first gather data about the client's nutritional status to provide the mental health professional with a comprehensive understanding of the client's condition.
A mental health consult can be helpful in addressing the client's distorted body image and underlying psychological issues, but it should not take precedence over assessing and addressing the client's immediate physical needs.
Choice D rationale:
Providing a structured environment for the client can be helpful in managing eating disorders, but it is not the first priority. The client's immediate physical needs, such as nutritional status, should be addressed first.
A structured environment may include regular mealtimes, supervision during meals, and restrictions on activities that could be used to compensate for food intake (such as excessive exercise). However, these interventions are more effective when implemented in conjunction with addressing the client's underlying psychological issues.
Choice B rationale:
Identifying the client's nutritional status is the first priority because it will provide essential information about the severity of the client's malnutrition and any potential medical complications. This information will guide the nurse in developing an appropriate plan of care, including dietary interventions, mental health referrals, and other necessary measures.
A thorough nutritional assessment should include:
A review of the client's dietary intake, including the types and amounts of foods consumed, as well as any restrictions or avoidance of certain foods.
A physical examination to assess for signs of malnutrition, such as muscle wasting, dry skin, hair loss, and edema. Laboratory tests to evaluate electrolyte levels, blood glucose levels, and other nutritional markers.
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