A nurse is caring for a client who has schizophrenia.
The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

Choice A rationale

Reporting the observation to the immediate supervisor is the most appropriate and ethical action. The nurse is a mandated reporter for such events within the healthcare setting. The supervisor, in their administrative role, is responsible for initiating a formal investigation into the matter, ensuring due process, and taking necessary disciplinary action according to institutional policy. This approach protects both the client and the nurse, who is acting on observed evidence, and maintains a chain of command.

Choice B rationale

Confronting the assistive personnel (AP) directly is an inappropriate and potentially unsafe action. This approach could escalate the situation, lead to a hostile confrontation, and create an unsafe work environment. The nurse's role is not to act as a law enforcement officer or to administer disciplinary action. The proper channel for addressing a suspected theft is through the established reporting structure, which involves informing the immediate supervisor. This maintains professional boundaries and ensures a fair and impartial investigation.

Choice C rationale

Telling the client that the assistive personnel (AP) took their watch is premature and unprofessional. The nurse has only observed the AP with a watch, but has not yet confirmed it is the client's. Making such an accusation directly to the client could be slanderous, cause emotional distress, and is not a factual statement. The proper procedure is to report the observation to the supervisor and allow the official investigation to proceed, which will determine the facts before any conclusions are drawn or communicated.

Choice D rationale

Calling security before the assistive personnel (AP) leaves the building is an excessive and premature action. The nurse's role is to report concerns to the immediate supervisor, who will then follow the proper institutional procedures, which may include contacting security if deemed necessary. Bypassing the chain of command and taking unilateral action could create a chaotic and unmanaged situation, potentially infringing on the AP's rights. The supervisor is the designated authority to manage such incidents and coordinate with other departments as needed. *.

Choice A rationale

Veracity is the ethical principle of telling the truth and being honest with clients. By informing the client about the potential side effect of lightheadedness while also clarifying that the procedure should not affect their memory, the nurse is providing accurate and complete information. This honesty allows the client to make an informed decision and builds trust in the therapeutic relationship. The nurse is being truthful about the known risks and benefits of the treatment.

Choice B rationale

Beneficence is the ethical principle of doing good and acting in the best interest of the client. While the nurse's actions are ultimately intended to be beneficial, the specific act of providing truthful information is a demonstration of veracity. Beneficence would involve ensuring the treatment is appropriate and safe for the client, whereas veracity is the specific communication of the truth about that treatment's effects.

Choice C rationale

Autonomy is the ethical principle that respects a client's right to self-determination and to make their own decisions. While providing truthful information supports the client's ability to exercise their autonomy, the act of giving the information itself is an example of veracity. The nurse is upholding the client's autonomy by being truthful, but the action of being truthful is the core principle demonstrated.

Choice D rationale

Fidelity is the ethical principle of keeping promises and being loyal to the client. This involves maintaining professional commitments and a trusting relationship. While providing accurate information contributes to a trusting relationship, it is a direct fulfillment of the duty of veracity. Fidelity is more about honoring commitments and promises, which is a broader concept than simply telling the truth about a procedure's effects. *.