A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about he desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?
"I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
"Because you are a minor, I have to share any information that I feel is important with your parents."
"I cannot promise that. I must share this information with other members of the team who are responsible for planning your care,"
The Correct Answer is D
A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."
While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.
B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."
This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.
C. "Because you are a minor, I have to share any information that I feel is important with your parents."
While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.
"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."
Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["24"]
Explanation
To calculate the mL/hr for the heparin infusion, you can use the formula:
mL/hr = (Total units required per hour) / (Units/mL in the solution)
Given:
Total units required per hour = 1,200 U/hr
Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL
Plugging in the values:
mL/hr = (1,200 U/hr) / (50 U/mL)
mL/hr = 24 mL/hr (rounded to the nearest tenth)
Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.
Correct Answer is ["1.5"]
Explanation
To calculate the number of clozapine 200 mg tablets needed to administer a total of 300 mg, divide the total dose by the dose per tablet:
300 mg / 200 mg = 1.5 tablets
Since you cannot administer half of a tablet, you would need to administer 2 tablets to achieve a total of 300 mg.
So, the nurse should administer 2 tablets of clozapine 200 mg each to achieve a total dose of 300 mg.
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