A nurse on a medical-surgical unit is caring for a client who asks to review his medical record.
Which of the following responses should the nurse make?

Choice A rationale

Asking the assistive personnel (AP) to observe the other nurse is inappropriate as the AP is not authorized or trained to monitor for controlled substance diversion, which is a serious ethical, legal, and professional matter. This action delegates a complex nursing responsibility to unlicensed personnel, violating professional standards and potentially compromising client safety and confidentiality. Reporting to the charge nurse is the appropriate chain of command.

Choice B rationale

Informing the charge nurse is the mandatory and appropriate first step according to professional and institutional policies. The charge nurse is the immediate supervisor, responsible for unit operations, and is trained to initiate the formal process for investigating suspected diversion of controlled substances, ensuring client safety and adherence to legal and ethical requirements. This follows the chain of command.

Choice C rationale

Reporting directly to hospital security bypasses the immediate supervisory chain of command (charge nurse/nurse manager). While security may become involved later in the investigation, the initial concern about a breach of professional conduct and potential client safety issue should first be reported to the unit's nursing leadership for immediate action and formal documentation.

Choice D rationale

Approaching the nurse directly is not the recommended procedure due to the serious nature of drug diversion. This action could escalate the situation, potentially put the reporting nurse at risk, and fail to initiate the formal, confidential, and unbiased investigation required to protect clients, staff, and the integrity of medication administration processes.

Choice A rationale

Providing assurance about the AP's capabilities dismisses the client's expressed preference and potential discomfort, infringing on the client's right to refuse care by a specific individual, especially for sensitive personal care. It fails to acknowledge the importance of dignity, autonomy, and cultural or personal comfort in the patient-provider relationship, which should be prioritized in care delivery.

Choice B rationale

Asking the client "why" may put them in a position of defensiveness or unnecessary explanation about a sensitive, personal matter, potentially violating their right to privacy and respect for personal boundaries. While understanding the reason can be helpful, the initial, respectful, and therapeutic response should prioritize a solution that honors their autonomy and comfort in their care.

Choice C rationale

Arranging for a male AP directly respects the client's autonomy and right to choose who provides their personal care, particularly for intimate hygiene. This therapeutic response maintains professionalism, accommodates the client's stated preference, and ensures continuity of necessary care while respecting cultural or personal boundaries and dignity.

Choice D rationale

While notifying the charge nurse is a correct procedural step for delegation changes, it is not the most immediate therapeutic response to the client. The nurse should first offer a direct, immediate solution that respects the client's right to request a provider of the same sex for personal care, as client autonomy is paramount.