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?

A. Keep the client hospitalized until there is no longer a threat: The nurse cannot independently detain a client without legal authorization or a provider’s order. Hospitalization may be necessary for safety, but the legal duty focuses on warning the potential victim. B. Ensure the client’s ex-partner is notified of the threat: The nurse has a legal and ethical duty to warn the identified potential victim or notify law enforcement. This responsibility, known as the duty to warn, is based on the Tarasoff ruling and aims to protect identifiable individuals from harm. C. Ask a friend or family member to monitor the client: Involving others in monitoring the client may violate confidentiality and does not fulfil the nurse’s legal duty to warn or protect the potential victim. Only appropriate authorities or the potential victim should be informed. D. Transfer the client to a mental health facility: Transferring the client may support ongoing treatment and safety but does not address the immediate legal responsibility. The nurse must first ensure the threatened individual is warned before any transfer occurs.