A nurse is caring for a client who is receiving hospice care and refusing pain medication. Which response by the nurse is therapeutic?

Choice A reason: Documenting a client’s refusal is standard professional practice and not lateral violence.

Choice B reason: Reporting an error to a supervisor is responsible professional behavior, not lateral violence.

Choice C reason: Delegating tasks appropriately is part of nursing practice and does not constitute lateral violence.

Choice D reason: Lateral violence includes acts of sabotage, withholding information, belittling, or undermining peers. Withholding important shift information negatively impacts colleagues and patient care, fitting the definition of lateral violence.

Choice A reason: Restlessness is not a common side effect of St. John’s wort. While some herbal remedies may cause mild agitation, this is not a primary adverse effect associated with this herb.

Choice B reason: Hirsutism, or excessive hair growth, is unrelated to St. John’s wort. This side effect is more commonly associated with hormonal imbalances or certain medications, not herbal antidepressants.

Choice C reason: Photosensitivity is a well-documented side effect of St. John’s wort. The herb increases sensitivity to sunlight, which can result in skin reactions such as rashes or burns. Clients taking this remedy should be advised to use sun protection and avoid prolonged sun exposure.

Choice D reason: Insomnia can occur with some antidepressants, but it is not a primary adverse effect of St. John’s wort. The herb is more commonly associated with photosensitivity rather than sleep disturbances.