A nurse is caring for a young adult client who says he is experiencing increased anxiety and an inability to concentrate. Which of the following responses should the nurse make?

A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.

B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."

This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.

C. "Because you are a minor, I have to share any information that I feel is important with your parents."

While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.

"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."

Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.

A. "We can call your family in time for them to get here."

While involving the family is important, this response assumes that the client's concern is solely about family being present. The client's statement might have deeper emotional layers, such as fear or regret, that should be addressed.

B. "Tell your family of your concern so that they can be here."

This response puts the responsibility on the client to communicate their concerns to the family. The nurse's role is to provide support and facilitate communication, rather than placing the burden on the client.

C. "I will make sure a staff member is in your room at all times."

While ensuring the client is not alone is important, this response doesn't address the client's emotional concerns or open a dialogue about their feelings. Simply having a staff member present might not address the underlying fear or anxiety the client is experiencing.

D. "I wonder if you are fearful of dying alone."

Explanation: The nurse's response empathizes with the client's feelings and invites a conversation about their emotions. It acknowledges the client's concerns and opens the door for a more in-depth discussion about their fears and feelings regarding dying alone. This approach is patient-centered and encourages the client to express their emotions.