# Situation: A nurse in a psychiatric day-hospital program holds weekly one-to-one sessions with a 29-year-old woman who has borderline personality disorder. In their first meeting they agreed on 10 sessions. Early in the first session she says, "I will tell you something only if you promise not to tell anyone on the team." What should the nurse do?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630097  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A nurse in a psychiatric day-hospital program holds weekly one-to-one sessions with a 29-year-old woman who has borderline personality disorder. In their first meeting they agreed on 10 sessions.

Early in the first session she says, "I will tell you something only if you promise not to tell anyone on the team." What should the nurse do?

## 보기

1. Promise to keep it private, since trust is built in this phase
2. Tell her secrets are not allowed in the relationship with a nurse
3. Ask her to share it with the psychiatrist rather than with the nurse
4. Explain when information she shares must be passed to the team **✔ 정답**

**정답: 4**

## 해설

In the orientation phase the nurse sets the contract, including the limits of confidentiality. The nurse never promises to keep a secret that may involve danger to self or others; information that points to danger to herself or others is shared with the team, so the client should know this before she decides what to share.

## 심화 해설

Therapeutic relationship and the orientation phase

The nurse is in the orientation phase of the nurse–client relationship with a client who has borderline personality disorder. This phase is not only about building rapport; it is the time to establish the contract, which includes the purpose of the sessions, the number of meetings, and the limits of confidentiality. The client explicitly asks the nurse to promise not to tell anyone on the team. The nurse cannot make that promise because information indicating danger to self or others must be shared with the treatment team. The correct response is to explain the boundaries of confidentiality before the client decides what to disclose.

Key point! A promise of absolute secrecy would be unsafe and unethical. The nurse must clarify the limits of confidentiality before the client shares sensitive material, not after.

Why the other options are incorrect

| Option | Why it is not the best response |
| --- | --- |
| 1. Promise to keep it private | This creates a boundary violation and a false contract. If the client later reveals self-harm or harm to others, the nurse would be forced to break the promise, damaging trust and potentially endangering the client. |
| 2. Tell her secrets are not allowed | This is overly restrictive and shuts down communication. Confidentiality is part of the therapeutic relationship, but it has defined exceptions. The nurse should not imply that no private information can be shared. |
| 3. Ask her to share it with the psychiatrist | This deflects the nurse’s responsibility and does not address the client’s request. The nurse is the appropriate person to clarify the limits of confidentiality within the nurse–client relationship. |

Applying the evidence to borderline personality disorder

Clients with borderline personality disorder often test boundaries and may experience intense fears of abandonment or rejection, which can lead them to seek exclusive alliances with one clinician. The caregiver must build a clear structure that serves as the basis for the therapeutic relationship, even when the client’s emotional dependency makes the bond feel fragile. Setting limits on confidentiality is part of that structure. The nurse maintains the relationship by being honest about what can and cannot remain private, rather than by making an impossible promise.

Watch out! A client with borderline personality disorder may interpret a refusal to promise secrecy as rejection. The nurse should explain the limits calmly and matter-of-factly, without becoming defensive or apologetic, so the client understands this is a professional standard, not a personal judgment.

What the nurse should say

The nurse can respond by stating that most information shared in sessions is confidential, but there are exceptions. For example, if the client reveals a plan to harm herself or someone else, or if there is a legal requirement to report, that information must be shared with the team to keep her safe. The client should know these limits before deciding what to share, so she can make an informed choice. This approach preserves trust while maintaining safety and professional boundaries.

Key point! The limits of confidentiality are established in the orientation phase, not discovered later when a crisis occurs. Explaining them early protects both the client and the nurse.

## 임상 시나리오

Confidentiality Limits in the Orientation PhaseSet the contract before sensitive disclosure
In the orientation phase, the nurse establishes the contract, including the limits of confidentiality. The client should know these limits before deciding what to share.

Information indicating danger to self or others must be shared with the treatment team. A promise of absolute secrecy is unsafe and unethical.

CautionNever promise to keep a secret that may involve danger to self or others. Clarify confidentiality boundaries before disclosure, not after, to avoid a false contract and boundary violation.

## 핵심 개념

- **Orientation phase** — The initial phase of the nurse-client relationship in which the contract, including purpose, number of sessions, and limits of confidentiality, is established.
- **Limits of confidentiality** — The defined exceptions to privacy in a therapeutic relationship, especially when information indicates danger to self or others.
- **Boundary violation** — An action that blurs the professional limits of the nurse-client relationship, such as promising absolute secrecy.
- **Borderline personality disorder** — A mental health condition characterized by instability in mood, relationships, and self-image, often requiring clear therapeutic boundaries.

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