An adolescent client is admitted to the pediatric observation unit following a syncopal episode. During the intake interview, the client tearfully reveals a suspected pregnancy and begs for confidentiality, stating, "My caregiver gets violently angry and left these bruises on my ribs when I failed a class last week." Suddenly, the client becomes severely agitated, grabs their belongings, and threatens to run out of the hospital into a busy intersection if the caregiver is contacted. Which of the following is the most appropriate legal and clinical action for the nurse to take?
- Initiate continuous one-to-one observation to ensure immediate safety and mandate a report to child protective services regarding the suspected physical abuse.Answer
- BPromise the client that their disclosures will remain strictly confidential to establish trust and de-escalate the immediate elopement risk.
- CSecure the client to the bed using soft limb restraints to prevent them from running into traffic while awaiting emergency psychiatric evaluation.
- DAssign the unlicensed assistive personnel (UAP) to assess the client's escalating anxiety levels while the nurse leaves the room to contact hospital security.
Answer
Initiate continuous one-to-one observation to ensure immediate safety and mandate a report to child protective services regarding the suspected physical abuse.
The nurse has a strict legal mandate to report suspected child abuse, which unequivocally overrides the adolescent client's request for confidentiality. Concurrently, the threat of running into traffic constitutes an immediate safety and elopement risk, necessitating the least restrictive effective intervention. Continuous one-to-one observation addresses the immediate physical danger legally and ethically without resorting to false imprisonment or premature restraint use.
Step-by-Step Solution
Key Concept
Mandatory reporting requirements and the application of least restrictive safety measures.