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

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved. Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

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

This option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

C. Ask a friend or family member to monitor the client

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

D. Transfer the client to a mental health facility

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

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Correct Answer is B

Explanation

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia: This activity involves providing support and education to individuals already experiencing a mental health condition and its associated complications. It falls under tertiary prevention, which focuses on minimizing the impact of established disease through treatment and rehabilitation.

B. Screening college students who demonstrate manifestations of depressive disorder: Screening individuals for depressive disorder symptoms, especially in a population known to be at risk (e.g., college students), aims to identify mental health issues early and intervene promptly. This falls under secondary prevention, which involves early detection and treatment to prevent the progression of a condition.

C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments: This activity focuses on improving communication and interaction skills with clients who have cognitive impairments. It falls under tertiary prevention, aiming to improve the quality of life and function of individuals already affected by cognitive impairment.

D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease: This activity aims to empower individuals with coping skills to manage the stress and challenges associated with having a parent with Alzheimer's disease. It falls under tertiary prevention, focusing on minimizing the negative consequences of an already existing condition.

A. "This medication will help control my child's aggressive behavior." B. “This medication can cause my child to have low blood sugar.” C. “This medication demonstrates won't require my child to have routine lab tests." D. “This medication might need to be increased if my child has muscle spasms."

Correct Answer is A

Explanation

A. "This medication will help control my child's aggressive behavior.": This statement demonstrates an understanding of the teaching. Risperidone is often prescribed to help manage aggressive behaviors and irritability in individuals with ASD.

B. “This medication can cause my child to have low blood sugar.”: This statement is not accurate. While risperidone can cause side effects such as weight gain and metabolic changes, low blood sugar is not a common side effect associated with this medication.

C. “This medication won't require my child to have routine lab tests.": This statement is incorrect. Routine monitoring, including blood tests, may be necessary while taking risperidone to monitor for potential side effects such as changes in blood sugar, cholesterol levels, and liver function.

D. “This medication might need to be increased if my child has muscle spasms.": This statement is partially accurate. Muscle spasms or extrapyramidal symptoms can be side effects of risperidone. However, the medication would typically be adjusted or possibly decreased if these side effects occur, rather than increased.

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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

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Correct Answer is A

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