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 C

Explanation

A reason: Provide additional attention to the client. While providing support and attention is important, it can reinforce attention-seeking behaviors in clients with borderline personality disorder. The care plan should balance support with boundaries.

B reason: Apply mechanical restraints before administering medication. Using restraints as a first-line intervention is not appropriate and should be avoided unless there is an immediate risk of harm. Less restrictive measures should be used initially.

C reason: Obtain a verbal contract from the client. A verbal contract, or a no-harm agreement, can be an effective strategy to engage the client in their own safety plan and reduce the risk of self-mutilation. It encourages the client to commit to seeking help before engaging in self-harm.

D reason: Limit staff members who work with the client. Consistency in care is important for clients with borderline personality disorder to build trust and maintain clear communication. Limiting staff changes helps provide stable and predictable care.

A. The child has a history of jaw fractures. B. The child seems frightened of their parent. C. The child has had no immunization since birth. D. The child rocks back and forth continually.

Correct Answer is C

Explanation

A reason: The child has a history of jaw fractures. While a history of fractures may indicate physical abuse, it is not specifically indicative of neglect. Child neglect often involves failure to provide necessary care, not necessarily causing physical injury.

B reason: The child seems frightened of their parent. Fear of a parent can be a sign of abuse or neglect, but it alone is not a definitive indicator of neglect. It requires further investigation to determine the cause of the child's fear.

C reason: The child has had no immunizations since birth. Failure to provide necessary medical care, such as immunizations, is a clear indicator of neglect. It shows a lack of attention to the child's health and well-being.

D reason: The child rocks back and forth continually. Repetitive behaviors like rocking can be a sign of psychological distress or developmental issues but are not specific indicators of neglect. They require further evaluation to understand the underlying cause.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Correct Answer is C

Explanation

A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

Correct Answer is C

Explanation

A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

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A nurse is caring for a client who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive. The nurse should identify these behaviors as manifestations of which of the following personality disorders?

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