A patient states, 'I'm going to shoot my husband when I go home.' What is the immediate nursing action?

• A. Notify law enforcement, the nurse in charge, the physician, and document the threat
• B. Document the statement and continue routine monitoring
• C. Do nothing until the physician orders an assessment
• D. Notify the patient’s family of the threat

Answer: (A)

When a patient directly threatens someone, safety is the top priority because there is an imminent risk of harm. This triggers a duty to warn or protect. The correct action is to immediately involve those who can take steps to ensure safety: notify the nurse in charge, inform the physician, and contact law enforcement, while also documenting the exact threat. This rapid coordination allows for appropriate risk assessment and intervention, such as supervision or hospitalization if needed. Simply documenting and monitoring, waiting for orders, or notifying the family does not address the immediate danger or protect the potential victim, and sharing the threat with family could breach confidentiality without reducing risk.