A client admitted for substance abuse detoxification displayed extreme anger toward their spouse. Which conclusion is supported by the documentation?

A client admitted for substance abuse detoxification displayed extreme anger toward their spouse. Which conclusion is supported by the documentation?

• A. The nurse responded appropriately and supported the patient
• B. The nurse documented the threat and alerted authorities
• C. The nurse responded inappropriately, because the threat of harm to the spouse was unaddressed
• D. The nurse referred the spouse to counseling

Answer: (C)

The key idea here is the duty to warn and protect others when a patient poses a potential danger. When a person being treated for substance use expresses intense anger toward a spouse, there is a real concern for possible harm. Ethical and professional standards require more than just recording the threat; they require taking steps to reduce risk and protect the potential victim. This is the Tarasoff-like duty: assess the seriousness of the threat, determine credibility, and take protective actions such as notifying authorities or the spouse, arranging safety measures, or involving the treatment team to ensure safety. So, documenting the threat without taking action to address it leaves the spouse unprotected and the patient potentially at risk, which is why the conclusion is that the nurse responded inappropriately. Simply put, appropriate care in this situation includes proactive steps to safeguard the spouse, not just noting the threat. The other options don’t fit because they either imply no danger exists or rely on referrals alone, whereas the situation demands concrete protective actions.

The key idea here is the duty to warn and protect others when a patient poses a potential danger. When a person being treated for substance use expresses intense anger toward a spouse, there is a real concern for possible harm. Ethical and professional standards require more than just recording the threat; they require taking steps to reduce risk and protect the potential victim. This is the Tarasoff-like duty: assess the seriousness of the threat, determine credibility, and take protective actions such as notifying authorities or the spouse, arranging safety measures, or involving the treatment team to ensure safety.

So, documenting the threat without taking action to address it leaves the spouse unprotected and the patient potentially at risk, which is why the conclusion is that the nurse responded inappropriately. Simply put, appropriate care in this situation includes proactive steps to safeguard the spouse, not just noting the threat. The other options don’t fit because they either imply no danger exists or rely on referrals alone, whereas the situation demands concrete protective actions.