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 D
Explanation
Choice A reason: This describes tactile hallucinations, a false sensory experience, not a delusion of reference.
Choice B reason: This reflects a persecutory delusion, where the client believes they are being harmed or targeted, not a delusion of reference.
Choice C reason: This illustrates an auditory hallucination with command-type voices, not a delusion of reference.
Choice D reason: Believing that unrelated environmental cues (like a song) carry special, hidden meaning specifically for the client is the hallmark of a delusion of reference.
Correct Answer is D
Explanation
Choice A reason: NANDA-I provides standardized nursing diagnoses but does not list or categorize symptoms for specific psychiatric disorders.
Choice B reason: The Nursing Outcomes Classification focuses on measurable patient outcomes after interventions, not on identifying symptoms of mental disorders.
Choice C reason: The Nursing Interventions Classification outlines evidence-based nursing actions and strategies, but it does not define or organize psychiatric symptoms.
Choice D reason: The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) is the authoritative resource for identifying and categorizing symptoms of mental disorders. It provides diagnostic criteria and symptom patterns for each psychiatric condition, making it the correct choice.
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