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 ["A","D"]

Explanation

Choice A rationale

Expressing increased comfort with their altered appearance in the mirror indicates a positive step towards acceptance of the changed body image following a mastectomy. This suggests the client is beginning to integrate the physical changes into their self-perception and is moving towards adaptation.

Choice B rationale

Worrying about a partner's perception, while a normal concern, does not necessarily indicate acceptance of the altered body image. It suggests preoccupation with external validation and potential insecurity about the physical changes' impact on the relationship, rather than internal acceptance.

Choice C rationale

Preferring loose-fitting clothing to conceal the changes suggests a desire to hide the altered body rather than accepting it. This behavior indicates a lack of comfort and potentially negative feelings about the mastectomy's physical consequences, hindering the process of body image adaptation.

Choice D rationale

Focusing on recovery and adapting to the changes demonstrates a proactive and accepting attitude towards the altered body image. This statement indicates a willingness to integrate the changes into their life and move forward, signifying a positive adjustment to their post-mastectomy self-perception.

A. Aripiprazole. B. Quetiapine. C. Bupropion. D. Risperidone.

Correct Answer is C

Explanation

Choice A rationale

Aripiprazole is an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar disorder. It is not indicated for smoking cessation. While some individuals with mental health conditions also smoke, aripiprazole does not directly address nicotine dependence.

Choice B rationale

Quetiapine is another atypical antipsychotic medication used for the treatment of schizophrenia and bipolar disorder. Similar to aripiprazole, it does not have pharmacological properties that aid in smoking cessation.

Choice C rationale

Bupropion is an atypical antidepressant that has also been approved for smoking cessation. It is thought to work by affecting dopamine and norepinephrine levels in the brain, which are involved in nicotine addiction and withdrawal symptoms.

Choice D rationale

Risperidone is an atypical antipsychotic medication used to treat psychotic disorders. It does not have any known efficacy in aiding smoking cessation.

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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 client following a mastectomy.Which of the following responses by the client indicates acceptance of their altered body image?

Correct Answer is ["A","D"]

Explanation

A nurse is providing information to a client about smoking cessation.Which of the following medications should the nurse include?

Correct Answer is C

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?