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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Correct Answer is C

Explanation

Choice A rationale

Depression is a mood disorder characterized by persistent sadness, loss of interest, and feelings of hopelessness. While it can co-occur with alcohol use disorder, it is not typically the initial manifestation of acute alcohol withdrawal. Acute withdrawal primarily involves physiological and neurological symptoms resulting from the abrupt cessation of alcohol consumption.

Choice B rationale

Delusions are fixed false beliefs that are not based in reality. These are more characteristic of severe alcohol withdrawal, such as delirium tremens, or other psychotic disorders, rather than the initial stage of acute withdrawal. The initial stage is typically marked by milder symptoms related to central nervous system hyperactivity.

Choice C rationale

Tremors, particularly hand tremors, are a common and characteristic early sign of acute alcohol withdrawal. Alcohol has a depressant effect on the central nervous system. When alcohol consumption is stopped, the central nervous system rebounds, leading to increased neuronal excitability. This hyperactivity manifests as tremors, along with other symptoms like anxiety and increased heart rate.

Choice D rationale

Bradycardia, a heart rate below 60 beats per minute, is not a typical finding in the initial stage of acute alcohol withdrawal. Instead, the sympathetic nervous system activation that occurs during withdrawal usually leads to tachycardia (an elevated heart rate) and hypertension as the body attempts to compensate for the absence of alcohol's depressant effects.

A. Reaction formation. B. Splitting. C. Projection. D. Suppression.

Correct Answer is D

Explanation

Choice A rationale

Reaction formation involves behaving in a way that is the opposite of one's true feelings. The client's statement focuses on delaying health concerns rather than expressing the opposite of their anxiety about their diagnosis.

Choice B rationale

Splitting is a defense mechanism where individuals view themselves or others as all good or all bad. The client's statement does not demonstrate this polarized thinking; instead, it shows a postponement of addressing their health.

Choice C rationale

Projection involves attributing one's own unacceptable thoughts or feelings onto another person. The client is not attributing their feelings about their cancer diagnosis to someone else; they are simply putting off thinking about it.

Choice D rationale

Suppression is a conscious or semiconscious effort to avoid thinking about disturbing thoughts or feelings. The client is consciously stating their intention to not think about their cancer diagnosis until after their son's wedding, indicating a deliberate avoidance of the topic.

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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 caring for a client who has alcohol use disorder.Which of the following findings should indicate to the nurse that the client is experiencing the initial stage of acute withdrawal?

Correct Answer is C

Explanation

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Correct Answer is D

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?