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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This response is factual but does not promote engagement or address the client’s passive stance. It emphasizes the nurse’s role without encouraging participation or collaboration from the older adult.
Choice B reason: This statement makes an assumption about the client’s feelings, labeling them as “angry,” which may not be accurate. It risks creating defensiveness and does not foster open communication or trust within the group.
Choice C reason: This response inappropriately offers group leadership to a member without assessing readiness or interest. It minimizes the therapeutic structure of the group and could confuse roles, making the group less effective.
Choice D reason: This option balances the acknowledgment of the nurse’s leadership role with an invitation for the client to share personal goals. It encourages involvement, respects autonomy, and helps build a therapeutic alliance by showing interest in what the older adult wants to accomplish.
Correct Answer is A
Explanation
Choice A reason: Odd beliefs, magical thinking, social anxiety, and eccentric behaviors are characteristic of schizotypal personality disorder, which belongs to Cluster A (odd and eccentric disorders).
Choice B reason: Dramatic, exaggerated emotional expression and attention-seeking behavior reflect histrionic personality disorder, which is classified under Cluster B (dramatic, emotional, or erratic disorders).
Choice C reason: Avoidance of relationships due to fear of rejection and inadequacy, despite desiring connection, is typical of avoidant personality disorder, which falls under Cluster C (anxious or fearful disorders).
Choice D reason: Arrogance, lack of empathy, and entitlement describe narcissistic personality disorder, which is in Cluster B.
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