A nurse is caring for a client with schizophrenia who expresses intent to harm a former partner. Which of the following actions by the nurse best demonstrates application of the "duty to warn exception to client confidentiality?
Explanation & Rationale
A. Informing hospital security and placing the client on one-to-one observation: While this addresses immediate safety within the facility, it does not fulfill the legal and ethical obligation to warn a potential victim outside the facility. It is a precautionary step but does not satisfy the “duty to warn.” B. Documenting the client's statement and notifying the healthcare team at shift change: Documentation and team notification are important for continuity of care and internal safety, but they do not address the external legal responsibility to warn a specific threatened individual. C. Discussing the threat with the client's family to gain insight into past behavior: Consulting family members may provide context but does not fulfill the duty to warn or protect the potential victim. It also risks breaching confidentiality without fulfilling the legal obligation. D. Reporting the threat to law enforcement and initiating steps to notify the intended victim: This action directly applies the “duty to warn” exception to client confidentiality. The nurse takes legally mandated steps to protect the potential victim while balancing ethical responsibilities, ensuring both public safety and professional compliance.