A nurse is escorting a client to their car following discharge from an acute mental health facility.
The client states their intentions to harm a friend after leaving the facility.
Which of the following actions should the nurse take?

Maintain the confidentiality of the client's statement.

Notify local law enforcement about the client's threat.

Prevent the client from leaving the facility.

Ask for the client's consent to notify the friend.

Assess the client's intent and ability to carry out the threat.

Answer and Explanation

Correct Answer : B,C,E

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. .

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Taking responsibility for actions – Improvement: Indicates self-awareness and emotional progress.
Talking about feelings in therapy – Improvement: Actively engaging in therapy is a positive sign.
Reporting headache pain – Unrelated: Physical symptoms like mild headaches may not be directly related to the condition.
Notifying staff of a new self-inflicted wound – Worsening: Self-harm remains a concern, though acknowledging it shows some insight.
Listening attentively to peers – Improvement: Demonstrates increased engagement and emotional openness.

A. Bruises noted in various stages of healing to the face, bilateral arms, and abdomen. B. Laceration to the left cheek cleansed and covered with an adhesive bandage. C. Left shoulder cleansed, antiseptic ointment applied, and covered with gauze dressing. D. Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.” E. Client has been married for 22 years and has two children. F. Client works part-time and volunteers at a community center. G. Client is tearful, does not make eye contact, and only speaks when spoken to. H. Client requests not to notify their partner because they do not want them to have to miss work or worry. I. Client reports poor appetite and difficulty sleeping.

Correct Answer is ["A","D","G","H","I"]

Explanation

The findings that indicate possible partner violence and should be reported to the provider include:

Bruises noted in various stages of healing to the face, bilateral arms, and abdomen.
Client is tearful, does not make eye contact, and only speaks when spoken to.
Client reports poor appetite and difficulty sleeping.
Client requests not to notify their partner because they do not want them to have to miss work or worry.
Client states, “I fell getting out of the shower and scraped my face and shoulder on the bathroom counter. I tried to catch myself when I fell, and that is how I broke my arm.”

These signs, particularly the bruising in different healing stages, avoidance of eye contact, emotional distress, reluctance to notify the partner, and vague or inconsistent injury explanations, may indicate potential intimate partner violence. Ensuring proper screening, support, and intervention is crucial in situations like these. The client’s safety and well-being should remain a priority, and reporting these findings to the healthcare provider allows for further assessment and assistance.

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A nurse is escorting a client to their car following discharge from an acute mental health facility.The client states their intentions to harm a friend after leaving the facility.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a 40-year-old female client on an inpatient mental health facility. Exhibits For each finding, click to specify if the finding indicates an unrelated condition, improvement of the condition, or worsening of the condition.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}

Explanation

Correct Answer is ["A","D","G","H","I"]

Explanation

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A nurse is escorting a client to their car following discharge from an acute mental health facility.
The client states their intentions to harm a friend after leaving the facility.
Which of the following actions should the nurse take?