A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about he desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
"I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
"Because you are a minor, I have to share any information that I feel is important with your parents."
"I cannot promise that. I must share this information with other members of the team who are responsible for planning your care,"
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Have a staff member escort the client to her room:
Having a staff member escort the client to her room might be perceived as restrictive and could potentially escalate the client's anxiety. It's important to give the client some autonomy and not force them into isolation.
B) Allow the client to pace alone until physically tired:
While allowing the client to pace alone might seem like a non-intrusive option, it lacks the therapeutic engagement that can help the client feel supported and understood. It's important for the nurse to actively engage with the client to establish a therapeutic relationship.
C) Instruct the client to sit down and stop pacing:
Instructing the client to stop pacing could potentially increase their agitation and anxiety. Forcing the client to sit down against their wishes might lead to resistance and hinder the development of trust between the nurse and the client.
D) Walk with the client at a gradually slower pace:
This is the correct answer. Walking with the client at a gradually slower pace is a therapeutic approach that allows the nurse to build rapport, provide support, and help the client regulate their emotions. It respects the client's need for movement while also addressing their emotional state.
Correct Answer is C
Explanation
A. "There really isn't much you can do about that until you are discharged." - This response dismisses the client's feelings and does not offer any support.
B. "You should call your boss and ask if you can have your job back." - This response is directive and may not address the client's emotional needs.
C. "You must feel very concerned and disappointed by that information."
This response shows empathy and acknowledges the client's feelings without making judgments or offering solutions. It validates the client's emotions and opens up a supportive space for further discussion.
D. "I don't understand why your partner would upset you with news like that." - This response may be perceived as judgmental and does not show empathy or understanding.
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