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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and dismissive of the client's request. It does not promote a therapeutic interaction and might escalate the situation.
B. "Go back to your room, and I'll try to get in touch with your doctor."
This response might temporarily calm the client, but it’s misleading if the nurse does not intend to call the doctor. It also avoids addressing the client's immediate emotional needs and could result in a loss of trust if the nurse doesn’t follow through.
C. "You must be very upset about something."
This is the most therapeutic response. It acknowledges the client’s feelings without judgment and opens up communication. It allows the nurse to explore the client’s concerns, which is essential in providing appropriate care and support in a psychiatric setting.
D. "I can't call a doctor in the middle of the night unless it's an emergency."
While this statement is factually correct, it can come across as dismissive and could escalate the client's agitation. It does not acknowledge the client's emotions and might make the client feel that their concerns are not being taken seriously.
Correct Answer is C
Explanation
Sharing personal information can blur the professional boundaries and might not be effective in reducing the client's suspicion. It's important to maintain a professional demeanor while building trust.
B) Approach the client frequently throughout the day for brief interactions:
While it's important to establish a presence and provide support, approaching the client too frequently might increase their discomfort and reinforce their suspicion. It's better to allow the client some personal space while ensuring they know you are available when needed.
C) Adopt a neutral attitude when providing care.
Explanation:
When dealing with a client who is extremely suspicious, it's important for the nurse to approach the situation with a neutral attitude. A neutral attitude helps to build trust and minimize any potential triggers for the client's suspicion. This approach creates a non-threatening environment where the client may feel more comfortable and gradually begin to open up.
D) Wait for the client to initiate interaction:
While giving the client space is important, waiting for them to initiate interaction might prolong the development of a therapeutic relationship. Clients who are extremely suspicious might have difficulty initiating interactions due to their concerns.
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