A nurse working in a psychiatric unit discovers that a client has disclosed intentions to harm a specific person outside the hospital. Balancing ethical principles, what is the nurse’s most appropriate action?
Break confidentiality to warn the victim and inform the healthcare team.
Immediately notify the victim without informing the treatment team.
Wait to see if the client acts on the threat before taking any action to respect client autonomy.
Maintain strict confidentiality and avoid disclosing the information to anyone.
The Correct Answer is A
Choice A reason: Nurses have a duty to protect potential victims from harm. Breaking confidentiality is justified to warn the intended victim and involve the healthcare team, consistent with the Tarasoff duty to warn principle.
Choice B reason: Warning the victim without involving the treatment team ignores the collaborative care process and may compromise safety planning.
Choice C reason: Waiting to act places the potential victim at risk and disregards the ethical duty to prevent harm.
Choice D reason: Maintaining confidentiality in this situation endangers others and violates the ethical principle of nonmaleficence.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Enhancing dopamine transmission is not the mechanism of antipsychotics; excessive dopamine is implicated in schizophrenia’s positive symptoms, so reducing—not enhancing—dopamine activity is key.
Choice B reason: Blocking both dopamine and serotonin receptors is characteristic of second-generation (atypical) antipsychotics. This dual action reduces extrapyramidal side effects while still targeting positive and negative symptoms.
Choice C reason: First-generation antipsychotics primarily block dopamine D2 receptors, which increases the risk for extrapyramidal side effects such as dystonia and parkinsonism.
Choice D reason: Selective serotonin receptor blockade is not the defining mechanism of second-generation antipsychotics. These medications act on both dopamine and serotonin systems.
Correct Answer is A
Explanation
Choice A reason: The M’Naghten Rule requires proof that, due to mental illness, the person did not understand the nature of the act or could not distinguish right from wrong at the time of the offense. This is the key standard used in many jurisdictions for insanity defenses.
Choice B reason: Having a history of mental illness alone is not sufficient; the rule focuses on the client’s mental state during the offense, not prior diagnoses.
Choice C reason: Being driven by uncontrollable impulses is not part of the M’Naghten criteria. This falls more under the “irresistible impulse” test, which is separate.
Choice D reason: Intoxication, even if it impairs judgment, does not qualify under the M’Naghten Rule. Voluntary substance use generally excludes insanity defenses.
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