A nurse on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

A reason: Keep the client hospitalized until there is no longer a threat. The nurse does not have the authority to independently keep the client hospitalized based on the threat. This decision involves a multidisciplinary approach and, if necessary, legal intervention.

B reason: Ensure the client's ex-partner is notified of the threat. The nurse has a legal and ethical duty to warn individuals who are at risk of harm. Ensuring the ex-partner is notified of the threat is an essential step to protect them from potential danger.

C reason: Ask a friend or family member to monitor the client. While involving friends or family in the client's care is important, it is not the primary legal duty in this situation. Professional intervention and appropriate authorities should be notified.

D reason: Transfer the client to a mental health facility. Transferring the client to a mental health facility may be necessary for their safety and well-being, but the immediate legal duty is to ensure the threatened individual is informed and protected.

A reason: Refer the client to a support group for survivors of suicide. While referring the client to a support group is important for long-term support, it is not the immediate priority in this acute moment of grief.

B reason: Offer to contact the client's family or support system. Offering to contact family or support systems is supportive but not the first priority. The nurse should first assess the client's immediate emotional and cognitive state.

C reason: Inform the client that feelings of guilt are often felt by survivors of suicide. Providing information about common feelings of guilt can be helpful, but the nurse should first understand the client's current state and their specific needs.

D reason: Determine the client's understanding of the suicide events. The first priority is to assess the client's understanding and emotional response to the news. This helps the nurse provide appropriate support and address any immediate misconceptions or distress.