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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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.

A. Refrain from judgmental comments about counting magazines. B. Teach the client how to use the technique of thought stopping. C. Assist the client to identify circumstances that increase anxiety. D. Remove magazines from the commons room when the client attends a group activity.

Correct Answer is ["A","B","C"]

Explanation

Choice A reason: Avoiding judgmental remarks supports therapeutic rapport and prevents worsening anxiety or defensiveness.

Choice B reason: Teaching coping strategies like thought stopping helps the client begin to manage obsessive behaviors more effectively.

Choice C reason: Identifying triggers for obsessive behaviors allows the nurse and client to develop strategies for prevention and management.

Choice D reason: Removing magazines to prevent counting avoids addressing the underlying compulsion and may increase anxiety. This approach is not appropriate in the initial care plan.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 psychiatric nurse is caring for several clients with personality disorders. The nurse understands that the DSM-5 groups these disorders into clusters based on characteristic behaviors. Which of the following client presentations is most consistent with a Cluster A personality disorder?

Correct Answer is A

Explanation

The nurse plans care for a client newly admitted with obsessive-compulsive disorder who is repeatedly counting magazines in the commons room. Which of the following should the nurse include in the initial plan of care? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

According to psychoanalytic theory, which of the following best describes the role of the superego in personality development and mental health?

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.)

A nurse is caring for a client who states, "I have no interest in sexual activity or finding a partner." The nurse should identify that this statement is consistent with which of the following personality disorders?

A 25-year-old client is hospitalized for severe anxiety. During the assessment, the nurse notices the client clutches a childhood stuffed animal and speaks in a childlike voice when discussing stressful life events. Which defense mechanism is the client most likely using?

A nurse is educating a client starting on risperidone. Which of the following statements best explains the unique pharmacological action of second-generation antipsychotics compared to first-generation antipsychotics?

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

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