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 C
Explanation
Choice A reason: Assigning leadership in a group setting may overwhelm a patient with schizoid personality disorder, as they are uncomfortable with close social interactions. This approach could increase withdrawal.
Choice B reason: Confrontation about avoidance behaviors is not therapeutic. It may heighten resistance and increase distress rather than encourage trust or engagement.
Choice C reason: Structured one-on-one interactions allow the nurse to build rapport while respecting the patient’s preference for limited emotional involvement. This is the most appropriate approach for schizoid personality disorder.
Choice D reason: Forcing daily group therapy participation may cause stress and withdrawal, as these patients are more comfortable with solitary activities. Gentle encouragement, not insistence, is better suited.
Correct Answer is D
Explanation
Choice A reason: Assault involves creating fear of being harmed, not the actual restraint of a client without justification.
Choice B reason: Malpractice is professional misconduct related to deviation from standards of care, but it does not specifically describe unlawful confinement.
Choice C reason: Negligence is the failure to act with reasonable care, but it is generally unintentional and not classified as an intentional tort.
Choice D reason: False imprisonment occurs when a person is confined or restrained against their will without legal justification, which directly applies to restraining a client without consent or physician’s order.
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