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
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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Related Questions
Correct Answer is B
Explanation
A. A client who is a voluntary admission does not have the right to request to be discharged.
This statement is incorrect. Clients admitted voluntarily to a mental health unit have the right to request discharge from the facility. However, there may be specific procedures and legal requirements to be followed for discharge, but the client ultimately has the right to request it.
B. A client who is admitted involuntarily has the right to refuse to participate in therapy.
This statement is generally true. Even if a client is admitted involuntarily, they still retain certain rights, including the right to refuse treatment such as therapy. However, there may be situations where treatment is deemed necessary for the client's safety or the safety of others, and in such cases, treatment may be provided against the client's wishes following appropriate legal processes.
C. A client who is admitted involuntarily cannot refuse to take prescribed psychotropic medications.
This statement is generally false. While involuntary admission may involve certain limitations on the client's autonomy, such as restrictions on leaving the facility, clients generally retain the right to refuse medications, including psychotropic medications. However, there are exceptions to this rule, such as when a client's refusal poses an imminent risk to their safety or the safety of others, in which case treatment may be provided following legal procedures.
D. A client who is a voluntary admission cannot withdraw consent after it has been given.
This statement is incorrect. Clients who are admitted voluntarily have the right to withdraw their consent for treatment or participation in any aspect of their care, including interventions previously agreed upon. However, similar to involuntary admissions, there may be situations where treatment is deemed necessary for the client's well-being, and in such cases, withdrawal of consent may be overridden following appropriate legal processes.
Correct Answer is A
Explanation
A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.
B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.
C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.
D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.
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