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.

Answer and Explanation

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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Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Sharing personal loss shifts the focus away from the patient, which is not therapeutic. Self-disclosure in this way can hinder supportive communication.

Choice B reason: Suggesting a grief support group acknowledges the patient’s feelings while offering a constructive coping resource. It validates distress and provides support.

Choice C reason: Leaving the patient when they are emotionally vulnerable conveys abandonment instead of support, which is not therapeutic.

Choice D reason: Normalizing grief as a process that takes time offers reassurance without minimizing the client’s emotions. It helps the patient understand that healing is gradual.

Choice E reason: Encouraging the patient to share coping strategies promotes expression of feelings and helps the nurse assess adaptive versus maladaptive coping mechanisms.

A. The role of classical conditioning in developing maladaptive responses. B. The modification of distorted thought patterns to change behavior. C. The use of psychoanalysis to uncover unconscious conflicts influencing behavior. D. The importance of unconditional positive regard, empathy, and fostering client growth.

Correct Answer is D

Explanation

Choice A reason: Classical conditioning is associated with behavioral theory, particularly the work of Pavlov, and is not central to Rogers’ humanistic approach.

Choice B reason: Changing distorted thought patterns reflects cognitive-behavioral therapy, which differs from Rogers’ emphasis on humanistic principles.

Choice C reason: Psychoanalysis focuses on unconscious drives and conflicts, a concept developed by Freud, not Carl Rogers.

Choice D reason: Rogers highlighted unconditional positive regard, empathy, and the belief in a client’s potential for growth as essential to therapeutic relationships, forming the foundation of his humanistic approach.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A recently widowed client becomes tearful at a routine clinic visit and states, "I just can’t get over my spouse’s death." Which of the following by the nurse are appropriate? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

Carl Rogers emphasized a humanistic approach in mental health nursing. Which of the following core concepts is central to his theory and therapeutic work?

Correct Answer is D

Explanation

A client recently diagnosed with cancer continues to miss follow-up appointments and states, "The doctors must have made a mistake—there’s no way I’m that sick." According to Freud’s psychoanalytic theory, which defense mechanism is the client most likely using?

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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?

The nurse assigned to care for the client with a diagnosis of histrionic personality disorder expects to observe which characteristics and behaviors?

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