A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require

______

as evidenced by the client’s

_______

and

______

.

A) Autonomy: Autonomy refers to the right of individuals to make their own choices and decisions. While the nurse’s actions may promote the client’s independence in the future, the nurse’s promise to walk with the client does not directly address or uphold the client’s autonomy. The nurse is offering support rather than encouraging the client to make independent decisions about their participation in the exercise.

B) Fidelity: Fidelity involves being faithful and keeping promises or commitments. In this scenario, the nurse promises to walk with the client in the courtyard each day, and this promise demonstrates the ethical principle of fidelity. The nurse is demonstrating trustworthiness and loyalty by committing to help the client overcome their anxiety and follow through with the daily exercise.

C) Justice: Justice is the ethical principle that focuses on fairness and equal treatment for all individuals. While justice is important in providing equal care to all clients, it is not the primary principle in this scenario. The nurse’s actions focus on meeting the specific needs of the individual client, which is more aligned with fidelity.

D) Nonmaleficence: Nonmaleficence means “do no harm.” While the nurse’s goal is to prevent harm by helping the client address their anxiety, the primary ethical principle at play here is fidelity, as the nurse is keeping their promise to provide consistent support. Nonmaleficence would be more relevant if the nurse were directly addressing potential harm or risk associated with the client’s situation, but the promise to walk with the client focuses more on the nurse’s commitment.

A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.

B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.

C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.

D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.

E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.

F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.