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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bulimia nervosa can be difficult to detect because individuals with the disorder often maintain a normal weight or may even be slightly overweight. Their eating and purging behaviors are often carried out in secret, and they may not appear outwardly ill or underweight, unlike individuals with anorexia nervosa.
Choice B rationale
People with bulimia nervosa engage in episodes of binge eating, consuming a large amount of food in a short period, followed by compensatory behaviors to prevent weight gain. Therefore, they do not eat an average amount of food on a daily basis; their intake is characterized by extremes.
Choice C rationale
Vomiting is one, but not the only, compensatory behavior associated with bulimia nervosa. Individuals may also use other methods such as misuse of laxatives, diuretics, excessive exercise, or fasting to counteract the effects of binge eating. The absence of vomiting does not rule out bulimia nervosa.
Choice D rationale
While bulimia nervosa has significant physical health consequences, the direct risk of developing diabetes mellitus is not a primary complication. Eating disorders can lead to various metabolic disturbances, but diabetes is more directly linked to factors like obesity, genetics, and insulin resistance. Electrolyte imbalances, esophageal damage, and cardiac arrhythmias are more immediate risks. .
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Access to firearms in the home significantly increases the risk of suicide because firearms are highly lethal and provide a quick and often impulsive means of ending one's life. The availability of a firearm reduces the time between suicidal ideation and action, making intervention more difficult.
Choice B rationale
A sibling history of suicide can increase an individual's risk due to potential genetic predispositions to mental health disorders or learned behaviors and coping mechanisms within the family. However, it is not as direct or immediate a risk factor as other factors.
Choice C rationale
Being currently unmarried can be a contributing factor to social isolation and lack of support, which are risk factors for suicide. However, marital status alone is not a strong predictor of suicide risk, as many unmarried individuals have strong social networks, and married individuals can still experience isolation.
Choice D rationale
Expressing feelings of hopelessness is a critical warning sign for suicide. Hopelessness is a state of despair where an individual believes their situation will never improve, leading to a sense of futility and a higher likelihood of considering suicide as an escape.
Choice E rationale
A recent significant loss, such as the death of a loved one, a job loss, or the end of a significant relationship, can trigger intense emotional distress and increase vulnerability to suicidal ideation, especially if the individual lacks adequate coping mechanisms or social support. .
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