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 D
Explanation
A. Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.
B. Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.
C. Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.
D. Delirium: Delirium is a state of acute confusion and altered consciousness characterized by disturbances in attention, awareness, cognition, and perception. Visual hallucinations and impaired consciousness are common features of delirium, especially in the context of alcohol withdrawal. Delirium often occurs due to underlying medical conditions, substance withdrawal, or medication side effects.
Correct Answer is C
Explanation
A. Cognitive reframing:
Cognitive reframing involves helping individuals change their perspective or interpretation of a situation to see it in a more positive or balanced light. While this technique can be helpful in various situations, it may not be suitable for addressing delusions or misconceptions in clients with dementia who firmly believe in their reality, such as the client who perceives a doll as her infant child.
B. Thought stopping:
Thought stopping is a cognitive-behavioral technique used to interrupt or stop intrusive or distressing thoughts. It typically involves mentally or verbally interrupting negative thoughts with a cue word or phrase. However, this technique may not be effective for addressing the belief of a client with dementia that a doll is her infant child because it does not acknowledge or validate the client's reality.
C. Validation therapy:
Validation therapy is a person-centered approach that acknowledges and validates the emotions and experiences of individuals with dementia, even if their perceptions do not align with objective reality. It involves empathetic listening, validation of emotions, and entering the individual's reality to provide comfort and support. This approach can help reduce agitation and distress in clients with dementia and foster a therapeutic connection between the client and the caregiver.
D. Operant conditioning:
Operant conditioning is a behavior modification technique based on the principles of reinforcement and punishment to strengthen or weaken behaviors. While it may be used to modify behaviors in some situations, it is not typically employed to address delusions or misconceptions in clients with dementia. Using operant conditioning techniques with a client who believes a doll is her infant child would not address the underlying emotional needs or provide therapeutic support for the client's reality.
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