An adolescent hospitalized after a physical outburst tells the nurse, "I’m going to kill my father, but you can’t tell anyone." Select the nurse’s best response.
You should share this thought with your psychiatrist
I’m concerned about your safety, so I must share this with the team
Let’s discuss why you feel this way
I promise I won’t tell anyone about this
The Correct Answer is B
Choice A reason: Suggesting the adolescent share with the psychiatrist avoids the nurse’s duty to report imminent threats. Ethical and legal standards require immediate action for safety, making this response inadequate, as it delays intervention in a potential crisis.
Choice B reason: Reporting a threat to harm others is a legal and ethical duty in psychiatric nursing, as it indicates imminent danger. Sharing with the team ensures safety interventions, aligning with mandatory reporting laws, making this the correct response.
Choice C reason: Discussing feelings is therapeutic but does not address the immediate safety risk of a threat. Prioritizing exploration over reporting violates ethical standards for managing dangerous behaviors, making this response incorrect in this context.
Choice D reason: Promising confidentiality in the face of a threat violates nursing ethics and legal mandates to report harm risks. This undermines patient and public safety, making it a non-therapeutic and incorrect response to a serious threat.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Fraudulent bankruptcy is a legal or ethical violation, not a psychiatric emergency. Involuntary hospitalization requires evidence of imminent danger to self or others due to a mental disorder. This behavior, while illegal, does not inherently indicate a mental health crisis necessitating forced psychiatric intervention, making this choice incorrect.
Choice B reason: Threatening harm to self and others meets legal and clinical criteria for involuntary hospitalization, as it indicates imminent danger due to a psychiatric condition. Mental health laws, such as the Baker Act, prioritize safety when a patient’s mental state poses significant risk, making this the correct choice for forced admission.
Choice C reason: Selling and distributing illegal drugs is a criminal act, not necessarily linked to a mental health crisis requiring involuntary hospitalization. While substance use disorders may involve psychiatric issues, this behavior alone does not demonstrate imminent danger due to mental illness, making it inappropriate for forced treatment.
Choice D reason: Noncompliance with treatment, while concerning, does not inherently indicate imminent danger or severe mental instability requiring involuntary hospitalization. It may reflect patient autonomy or other factors, not acute psychiatric risk. This choice fails to meet the legal or clinical threshold for forced admission, making it incorrect.
Correct Answer is B
Explanation
Choice A reason: Assault involves a threat of harm without physical contact. Forcing medication involves actual physical intervention, not just a threat, making assault incorrect. Battery better describes the unauthorized physical act in this scenario, as it involves direct contact.
Choice B reason: Battery is the unauthorized physical contact or use of force on a patient, such as forcibly administering medication against their objection. This violates patient autonomy and ethical standards, aligning with the scenario, making this the correct term for the nurse’s action.
Choice C reason: Negligence involves failing to meet a standard of care, causing harm, such as ignoring a patient’s needs. Forcing medication is an active violation, not a failure to act, making negligence incorrect for this intentional physical intervention.
Choice D reason: Malpractice involves professional negligence causing harm, typically through substandard care. Forcing medication is a deliberate act of battery, not a failure in skill or judgment, making malpractice less precise than battery for this scenario.
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