A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?

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.

Choice A rationale: A 13-year-old girl worrying about a pimple on her face is a common concern at this age. Adolescence is a time of significant physical changes, including the onset of acne. While this can cause distress and affect self-esteem, it is not as immediate a concern as some of the other options.

Choice B rationale: Menarche, or the onset of menstruation, typically occurs around the age of 12-14, but it can vary widely. Some girls may start their periods as early as 9 or as late as 16. This girl’s concern about not having started her period yet, while valid, is not unusual or immediately concerning given her age.

Choice C rationale: Feeling like one’s parents are treating them like a baby is a common sentiment among adolescents who are striving for more independence. It’s a normal part of the developmental process and, while it can cause conflict and frustration, it is not an immediate concern.

Choice D rationale: This statement indicates that the girl is feeling socially isolated, which can be a sign of social problems or mental health issues such as depression or anxiety. Social relationships and a sense of belonging are crucial for mental health, particularly during adolescence. This should be the nurse’s priority to address.

Please note that these rationales are based on general knowledge and understanding of adolescent development and mental health. For a more accurate and detailed explanation, it would be best to consult with a healthcare professional or refer to trusted health resources.