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 A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

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. A client who has a new diagnosis of major depressive disorder: While major depressive disorder can significantly impact functioning and may require treatment, it typically does not meet the criteria for ACT, which is primarily designed for individuals with severe and persistent mental illness.

B. A client who has repeated acute care admissions due to schizophrenia: Repeated acute care admissions due to schizophrenia suggest significant challenges in managing the illness and maintaining stability in the community. This client may benefit from the intensive support and comprehensive services provided by ACT to prevent future hospitalizations and promote community integration.

C. A client who has requested family therapy following the death of a family member: Family therapy may be an appropriate intervention for supporting this client's grieving process and addressing family dynamics. However, it does not necessarily indicate the need for ACT, which is focused on individuals with severe and persistent mental illness.

D. A client who has physical injuries following an incident of partner violence: While this client may require support and interventions to address the effects of partner violence, it does not specifically indicate the need for ACT unless there are underlying severe and persistent mental health issues contributing to the situation.

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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 caring for a client who reports a history of frequent alcohol consumption. Which of the following questions should the nurse ask when screening for alcohol use disorder?

Correct Answer is A

Explanation

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

Correct Answer is B

Explanation

A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?

A nurse in an acute mental health facility receives change-of-shift report on a group of clients. Which of the following clients should the nurse assess first?

A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

A charge nurse on a mental health unit is preparing an in-service for staff members about client rights. Which of the following information should the nurse include?

A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

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?

A nurse is assessing an older adult client's ability to make a successful role transition to widowhood following the death of her partner. Which of the following factors should the nurse include in the assessment? (Select all that apply.)

A nurse is reviewing the medical record of a newly admitted client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for this condition?