The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

Choice A reason: Violating a nurse’s boundaries, such as inappropriate behavior, does not legally mandate breaching confidentiality. Ethical responses involve setting boundaries or reporting within the care team, but confidentiality is protected unless harm to others is threatened, making this situation insufficient for a legal breach.

Choice B reason: Nurses are legally obligated to breach confidentiality when a client makes credible threats to harm an identifiable third party (Tarasoff duty). This protects potential victims by ensuring warnings or interventions occur, balancing patient confidentiality with public safety, as harm prevention takes precedence in mental health law.

Choice C reason: Client aggression does not automatically warrant breaching confidentiality unless it involves specific threats to identifiable individuals. Aggression is managed within the care setting, and confidentiality is maintained unless legal criteria, like imminent harm to others, are met, making this option incorrect.

Choice D reason: Disagreement with the nurse does not justify breaching confidentiality. Ethical care respects client autonomy, and confidentiality is protected unless legal exceptions, like threats or court orders, apply. Disagreement is managed through therapeutic communication, not by disclosing private information, making this an invalid reason for breach.

Choice A reason: Assault involves threatening harm, not applicable here, as the issue is failure to document assessments, not intentional threats by staff. The client’s self-harm resulted from inadequate monitoring, not a staff-initiated threat, making assault an incorrect legal issue in this scenario.

Choice B reason: Battery involves unauthorized physical contact, not relevant to failure to document assessments. The client’s self-harm stemmed from inadequate observation, not staff-inflicted harm, making battery an inappropriate legal claim compared to negligence in monitoring and documentation.

Choice C reason: Suicide risk is a clinical concern, not a legal issue to defend against. While the client’s self-harm indicates risk, the hospital’s liability arises from failure to follow monitoring protocols, not the risk itself, making this option incorrect for the legal defense context.

Choice D reason: Malpractice involves negligence, such as failing to document hourly assessments for a high-risk client, leading to harm. This breach of standard care (1:1 observation) allowed self-harm, making the hospital liable for not adhering to protocols, requiring defense against malpractice for inadequate monitoring and documentation.