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?

Keep the client hospitalized until there is no longer a threat.

Ensure the client's ex-partner is notified of the threat.

Ask a friend or family member to monitor the client.

Transfer the client to a mental health facility.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

A reason: "Have you thought about taking a sleeping pill?" Suggesting a sleeping pill does not address the underlying issues causing the client's fatigue and inability to grocery shop. It may also not be appropriate without further assessment.

B reason: "Your fatigue will pass, and everything will be just fine." This statement is dismissive and does not acknowledge the client's current struggle. It can make the client feel unheard and unsupported.

C reason: "Do you have a family member who can assist you?" While practical, this response shifts the responsibility away from the client and the nurse. It does not explore the client's feelings or needs comprehensively.

D reason: "Let's discuss how to get you the help you need." This response is an example of therapeutic communication as it shows empathy, acknowledges the client's feelings, and focuses on finding solutions. It encourages the client to talk about their needs and involves them in the care plan.

A. A client who has a new diagnosis of major depressive disorder. B. A client who has repeated acute care admissions due to schizophrenia. C. A client who has requested family therapy following the death of a family member. D. A client who has physical injuries following an incident of partner violence.

Correct Answer is B

Explanation

A reason: A client who has a new diagnosis of major depressive disorder. While clients with major depressive disorder need support, ACT is typically designed for clients with severe and persistent mental illnesses who require intensive, ongoing care.

B reason: A client who has repeated acute care admissions due to schizophrenia. Clients with schizophrenia who have frequent hospitalizations and difficulty managing their illness benefit from ACT. This program provides comprehensive, community-based care and support to reduce hospitalizations and improve quality of life.

C reason: A client who has requested family therapy following the death of a family member. Family therapy is more appropriate for addressing grief and loss. ACT is not typically indicated for clients dealing primarily with bereavement.

D reason: A client who has physical injuries following an incident of partner violence. Clients who have experienced partner violence may need crisis intervention, medical care, and counseling. ACT is not the primary referral for this situation unless the client also has a severe mental illness requiring intensive support.

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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?

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