Question

A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take?

A. Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to holding the knife.
B. Keep the client's communication confidential, but watch the client and his roommate closely.
C. Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.
D. Report the incident, but do not inform the client of the intention to do so.

ATI RN Mental Health Nursing Modules Ch. 2 Application Exercises

Answer 1

The nurse should inform the client that the presence of the knife must be reported due to safety concerns, thereby choosing option C. This maintains safety without breaching trust. Confidentiality is critical, especially for minors, but safety and preventing harm override these concerns in dangerous situations.

Step-by-step explanation:

The situation described calls for a balance between ensuring the safety of the client and others, and respecting patient confidentiality. The nurse should choose option C: Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. Safety concerns must take precedence over confidentiality in situations where there is a risk of harm to the client or others. The nurse should inform the client that they are obligated to report the presence of the knife, thus maintaining transparency and fostering trust.

In situations involving minors and sensitive issues such as sexual health, healthcare professionals must navigate the delicate balance between respecting adolescent confidentiality and the right of parents to be informed. Laws often provide guidance on these matters, but the principle of doing no harm should always be paramount. When it comes to sexual partners, notification policies typically aim to prevent the spread of infection while considering patient privacy rights.

.