A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
“I need to make sure that the potential victim is warned."
"I need to keep the information confidential due to the client's right to privacy."
“I can only discuss the client's threats with a court order."
"I should verbally report this information to the psychiatrist."
The Correct Answer is A
A. "I need to make sure that the potential victim is warned."
Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.
B. "I need to keep the information confidential due to the client's right to privacy."
Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.
C. "I can only discuss the client's threats with a court order."
Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.
D. "I should verbally report this information to the psychiatrist."
Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.
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Related Questions
Correct Answer is C
Explanation
A. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine.
The other options do not align with best practices for caring for a client with major depressive disorder:
B. Teaching passive communication is not appropriate, as assertive communication is typically encouraged to help the client express her needs and feelings effectively.
C.Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine
D. Limiting involvement in unit activities could further isolate the client and exacerbate her symptoms. Encouraging participation and engagement is generally more beneficial.
Correct Answer is D
Explanation
A. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route."
This response is directive and dismissive of the client's choice. It does not promote open communication or respect for the client's autonomy and beliefs.
B. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you."
While healthcare providers have expertise, this response doesn't address the client's concerns or give them an opportunity to express their feelings. It may come across as authoritarian and not respecting the client's wishes.
C. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice."
This response uses scare tactics and doesn't address the client's individual needs or concerns. It does not foster a trusting and respectful nurse-client relationship.
D. "Tell me more about your concerns about taking chemotherapy."
This is the most appropriate response. It demonstrates active listening, empathy, and a willingness to understand the client's perspective. By asking the client to share more about their concerns, the nurse can engage in a meaningful conversation and provide information and support based on the client's needs.
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