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. The client has a serotonin deficiency B. The client has acute bronchitis C. The client has an elevated calcium level D. The client is an only child

Correct Answer is A

Explanation

A. The client has a serotonin deficiency

This choice suggests a biological risk factor for major depressive disorder (MDD). Serotonin is a neurotransmitter associated with mood regulation, and alterations in its levels or function can contribute to the development of depressive symptoms. A deficiency in serotonin is considered a significant biological risk factor for MDD.

B. The client has acute bronchitis

Acute bronchitis, an inflammation of the bronchial tubes typically caused by viral infections, is not directly associated with major depressive disorder. While physical health issues can impact mental health and exacerbate depressive symptoms, acute bronchitis is not a recognized risk factor for MDD.

C. The client has an elevated calcium level

Elevated calcium levels are not typically considered a risk factor for major depressive disorder. While imbalances in electrolytes like calcium can have physiological effects on the body, they are not directly linked to the development of depression.

D. The client is an only child

Being an only child is a demographic characteristic and is not considered a direct risk factor for major depressive disorder. While family dynamics and relationships can influence mental health, being an only child alone is not causally related to the development of depression.

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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

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Explanation

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Correct Answer is A

Explanation

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