A nurse is assisting in the admission of a 30-year-old client to an inpatient mental health facility.

Exhibits

For each finding, click to specify if the finding is consistent with opioid, stimulant, or hallucinogen intoxication. Each finding may be consistent with more than 1 substance or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

Choice A rationale

Maintaining confidentiality is important in the nurse-client relationship; however, the duty to protect a third party from harm overrides confidentiality. When a client expresses intent to harm someone, the nurse has a legal and ethical obligation to take action to prevent that harm.

Choice B rationale

Notifying local law enforcement about the client's threat is a necessary step to ensure the safety of the potential victim. Law enforcement has the authority and resources to intervene and assess the situation, potentially preventing harm. This aligns with the duty to warn.

Choice C rationale

Preventing the client from leaving the facility is crucial to ensure the safety of the intended victim and to further assess the client's mental state. The client's stated intention to harm someone indicates a potential crisis that requires immediate intervention and prevents them from acting on their threat.

Choice D rationale

Asking for the client's consent to notify the friend is not the appropriate immediate action when there is a direct threat of harm. The safety of the potential victim takes precedence over the client's autonomy in this situation. Delaying notification could have serious consequences.

Choice E rationale

Assessing the client's intent and ability to carry out the threat is a critical step in determining the level of risk. This involves asking further questions about the specifics of their plan, their access to means, and their history of violence. This assessment will guide further intervention and safety measures. .

Choice A rationale

Encouraging communication with staff during self-harm urges is a crucial intervention for clients with borderline personality disorder. This allows for immediate support, redirection of focus, and the opportunity to implement coping strategies before an episode of self-harm occurs, aligning with the principles of dialectical behavior therapy often used for this disorder.

Choice B rationale

Assisting the client in developing healthy coping mechanisms for intense emotions is fundamental in managing borderline personality disorder. Individuals with this disorder often experience emotional dysregulation, and learning adaptive coping skills provides them with tools to manage distress, reduce impulsivity, and decrease the likelihood of self-harm.

Choice C rationale

Advising the client to avoid expressing feelings assertively is countertherapeutic. Clients with borderline personality disorder may struggle with expressing emotions appropriately. Encouraging avoidance can lead to suppressed feelings, potential emotional outbursts, and increased risk of self-harm. Assertive communication skills should be fostered.

Choice D rationale

Offering additional attention only when self-mutilating behaviors occur can inadvertently reinforce these behaviors. This approach can create a pattern where the client engages in self-harm to gain attention, rather than learning healthier ways to seek support and manage their emotions. Consistent and proactive support is more effective.