A nurse is caring for a client in the emergency department who states that she was beaten and sexually assaulted by her partner.
After a rapid assessment, which of the following actions should the nurse plan to take next?

Choice A rationale:

Individuals with borderline personality disorder often have difficulty establishing and maintaining boundaries. Providing consistent and clear boundaries helps in promoting a structured and safe environment for the client.

Choice B rationale:

Encouraging the use of countertransference is not appropriate. Countertransference refers to the therapist or nurse's emotional reactions to the client, and it is generally not encouraged as a therapeutic approach.

Choice C rationale:

Maintaining consistency in assigning healthcare staff for the client is essential in promoting stability and reducing anxiety. This is a crucial aspect of care for clients with borderline personality disorder.

Choice D rationale:

Demonstrating a sympathetic attitude is important in providing compassionate care, but it should be balanced with maintaining professional boundaries and not allowing manipulation by the client. Sympathy alone may not be sufficient in effectively managing the client's condition.

Choice A rationale:

Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.

Choice B rationale:

Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.

Choice D rationale:

Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.