A nurse is assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

Choice A rationale:

Intrusive and judgmental: Asking "Why did you wear clean clothes and comb your hair today?" directly challenges the client's behavior and implies that she needs to justify her actions. This can make the client feel defensive and less likely to open up.

Focuses on the past: The directs attention to the client's previous lack of self-care, which can reinforce negative feelings and discourage progress.

Assumes motivation: It presumes that the client made a conscious decision to change her appearance based on a specific reason, which may not be accurate and can invalidate her experience.

Choice B rationale:

Presumptuous and premature: Concluding that "Your mood must be lifting because you have on clean clothes and have combed your hair" makes assumptions about the client's internal state without proper assessment.

Oversimplifies depression: It suggests that improvements in self-care directly equate to mood improvement, which disregards the complexity of depression and its varied manifestations.

Can create pressure: The statement can inadvertently pressure the client to feel or act a certain way to meet the nurse's expectations, hindering genuine progress.

Choice D rationale:

Paternalistic and condescending: Expressing "Oh, I'm so pleased that you finally put on clean clothes" implies that the nurse has been waiting for or expecting this change, placing the nurse in a position of authority and potentially undermining the client's autonomy.

Focuses on the nurse's feelings: The statement centers on the nurse's approval rather than acknowledging the client's efforts and perspective.

Can reinforce dependency: It can foster a dynamic where the client seeks external validation for her actions, rather than developing internal motivation for self-care.

Choice C rationale:

Observational and non-judgmental: The statement "I see that you have on clean clothes and have combed your hair" simply acknowledges the client's actions without imposing any interpretation or judgment.

Invites conversation: It provides an opportunity for the client to elaborate on her choices if she feels comfortable, promoting autonomy and self-expression.

Validates effort: It subtly recognizes the client's efforts without explicitly praising or criticizing, fostering a sense of self- efficacy and encouraging continued self-care.

Demonstrates active listening: It shows that the nurse has been paying attention to the client's progress, which can strengthen the therapeutic relationship and build trust.

Choice A rationale:

While it's true that the nurse has released the client's information without their explicit consent, this action is justified under the duty to warn and protect.

This duty supersedes the general obligation to maintain confidentiality when there's a serious and imminent threat to identifiable individuals or the public.

In this case, the client's verbal threat to bomb a local church constitutes a credible and foreseeable risk of harm, necessitating the breach of confidentiality to protect potential victims.

Choice B rationale:

Although the nurse's actions may help to avoid malpractice charges by demonstrating responsible care and adherence to ethical obligations, this is not the primary reason for notifying the minister.

The primary goal is to avert harm and fulfill the duty to warn, not to shield oneself from legal liability.

Choice C rationale:

This is the correct answer. The nurse has acted in accordance with the duty to warn and protect, which is a legal and ethical obligation in healthcare.

This duty mandates that healthcare professionals take reasonable steps to warn potential victims and protect the public when a patient communicates a serious threat of harm.

Choice D rationale:

While confidentiality is a cornerstone of healthcare ethics, it's not absolute.

The duty to warn and protect allows for limited breaches of confidentiality when necessary to prevent serious harm, as in this case.

The nurse's actions align with ethical principles and legal requirements, even though they involve disclosing confidential information.