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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This presentation is consistent with neuroleptic malignant syndrome (NMS), a rare but life-threatening reaction to antipsychotics characterized by severe muscle rigidity, hyperthermia, altered mental status, and autonomic dysfunction. Immediate discontinuation of the drug and emergency treatment are required.
Choice B reason: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotics. While distressing and requiring management, it is not life-threatening compared to NMS.
Choice C reason: A flat affect and reduced speech are negative symptoms of schizophrenia and may persist despite treatment. These are concerning for quality of life but do not require urgent medical intervention.
Choice D reason: Mild weight gain is a known side effect of many antipsychotics. It should be monitored and managed with lifestyle modifications but does not represent an immediate threat.
Correct Answer is A
Explanation
Choice A reason: Redirecting the focus back to the patient in a therapeutic and nonjudgmental way ensures the conversation remains centered on the client’s needs. This maintains professional boundaries while being supportive.
Choice B reason: Stating that nurses direct interviews is authoritative and may come across as rigid. It does not encourage patient openness.
Choice C reason: Responding with a prohibition sounds harsh and judgmental. It could damage rapport and shut down communication.
Choice D reason: Asking "why" can make the patient feel defensive, which is not therapeutic. It shifts the focus to justification rather than reflection.
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