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: Role modeling involves demonstrating positive behaviors for others to emulate, often used in social learning. It does not involve applying negative stimuli like bitter substances to deter behaviors. Nail-biting treatment requires a direct intervention to discourage the habit, making this choice scientifically inappropriate.
Choice B reason: Aversion therapy uses an unpleasant stimulus, like a bitter substance, to create a negative association with an undesired behavior, such as nail-biting. This behavioral technique aims to reduce the behavior through conditioning, aligning with the described intervention, making this the correct choice for the therapy type.
Choice C reason: Milieu therapy focuses on creating a therapeutic environment to promote mental health, not targeting specific behaviors like nail-biting. It involves group dynamics and structured settings, not aversive stimuli. This approach is unrelated to the described intervention, making this choice incorrect.
Choice D reason: Desensitization therapy gradually exposes individuals to anxiety-provoking stimuli to reduce fear, commonly used for phobias. It does not involve aversive stimuli to deter behaviors like nail-biting. This therapy is unrelated to the described intervention, making it an incorrect choice for this scenario.
Correct Answer is C
Explanation
Choice A reason: Direct questions like "Did you feel angry?" may elicit specific information but can feel confrontational, limiting open dialogue. They focus on the nurse’s agenda rather than signaling attentive listening, which is critical for therapeutic communication in mental health, making this choice less effective.
Choice B reason: Asking "Why did you do that?" can seem judgmental, causing defensiveness and hindering open communication. It shifts focus to justification rather than fostering a safe space for the patient to share feelings, making it non-therapeutic and incorrect for showing listening interest.
Choice C reason: Maintaining eye contact and nodding are nonverbal cues that demonstrate active listening and empathy, encouraging patients to share openly. These align with therapeutic communication principles in psychiatric nursing, creating a supportive environment and fostering trust, making this the correct choice for showing interest.
Choice D reason: Offering advice based on personal experience shifts focus to the nurse, undermining the patient’s perspective. It risks blurring professional boundaries and is non-therapeutic, as it does not prioritize the patient’s feelings or encourage open dialogue, making this choice incorrect.
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