A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.

Choice A Reason:

“You should share this thought with your psychiatrist.”

This response suggests that the client should discuss their harmful thoughts with their psychiatrist. While it is important for the client to communicate openly with their mental health provider, this response does not directly address the nurse’s ethical and legal obligation to report threats of harm. The nurse has a duty to ensure the safety of others, and simply redirecting the client to another professional does not fulfill this responsibility. According to the Tarasoff rule, healthcare providers have a duty to warn potential victims if a client poses a credible threat.

Choice B Reason:

“I can make that promise to you based on nurse-client privilege.”

This statement is incorrect because nurse-client privilege does not extend to situations where there is a threat of harm to others. Confidentiality in healthcare is crucial, but it has limits, especially when it comes to preventing harm. Nurses are legally and ethically obligated to report any threats of violence or harm to appropriate authorities to protect potential victims. Making such a promise would be misleading and could result in serious consequences.

Choice C Reason:

“Those kinds of thoughts will make your hospitalization longer.”

This response is inappropriate as it focuses on the potential consequences for the client rather than addressing the immediate concern of a threat to another person’s safety. It may also discourage the client from being honest about their thoughts in the future. The primary responsibility of the nurse in this situation is to ensure the safety of the client and others, which involves reporting the threat to the appropriate authorities.

Choice D Reason:

“I cannot promise that. Confidentiality does not include plans to hurt others.”

This is the correct response. It clearly communicates to the client that while confidentiality is important, it does not cover plans to harm others. The nurse must explain that they are obligated to report any threats of violence to ensure the safety of potential victims. This response aligns with legal and ethical guidelines, which mandate that healthcare providers report credible threats of harm.

Choice A Reason:

The client diagnosed with a somatoform disorder should have any new medical complaint evaluated.

This is the correct response. Clients with somatoform disorders often experience physical symptoms that cannot be fully explained by any underlying medical condition. However, it is crucial to evaluate any new medical complaints to rule out any actual medical conditions that may require treatment. This approach ensures that the client receives comprehensive care and that any potential medical issues are not overlooked.

Choice B Reason:

The client diagnosed with a somatoform disorder can be easily cured with medication.

This statement is incorrect. Somatoform disorders are complex and often require a multifaceted treatment approach, including psychotherapy, behavioral interventions, and sometimes medication to manage associated symptoms like anxiety or depression. There is no simple cure for somatoform disorders, and treatment typically focuses on managing symptoms and improving the client’s quality of life.

Choice C Reason:

The client diagnosed with a somatoform disorder has a real medical diagnosis for their symptoms.

While clients with somatoform disorders experience real and distressing symptoms, these symptoms are not typically linked to a diagnosable medical condition. The symptoms are believed to be related to psychological factors, and the focus of treatment is often on addressing these underlying psychological issues rather than finding a medical diagnosis.

Choice D Reason:

The client diagnosed with a somatoform disorder intentionally pretends to have physical symptoms.

This statement is incorrect. Clients with somatoform disorders do not intentionally fake their symptoms. Their symptoms are real to them and cause significant distress and impairment. The symptoms are not under the client’s conscious control, and they genuinely believe they are experiencing a medical condition.