The nurse is completing an admission assessment of a client who is admitted to milieu. Which piece of information obtained from the client during the assessment would require immediate investigation from the nurse regarding the client’s use of complementary and alternative therapies?

Choice A Reason:

It is extremely important to maintain professional boundaries with clients.

Maintaining professional boundaries is crucial in nursing to ensure a therapeutic and trusting relationship between the nurse and the client. Crossing these boundaries can lead to ethical issues and compromise the care provided. In this scenario, the nurse allowed personal relationships to influence professional behavior, which is inappropriate and can undermine the client’s trust and the integrity of the nurse-client relationship.

Choice B Reason:

Countertransference may have been a factor in your actions with this client.

Countertransference occurs when a nurse’s personal feelings and experiences influence their professional interactions with a client. In this case, the nurse’s familiarity with the client as a childhood friend of a sibling may have led to biased actions, such as allowing the use of a personal mobile device and sharing confidential information. Recognizing and managing countertransference is essential to maintain objectivity and provide unbiased care.

Choice C Reason:

It would have been better if you called your sibling instead of texting.

This statement is not relevant to the primary issues at hand. Whether the nurse called or texted their sibling does not change the fact that sharing the client’s hospitalization status was a breach of confidentiality. The focus should be on the inappropriate disclosure of protected health information, not the method of communication.

Choice D Reason:

Policies can be amended for clients who are admitted voluntarily, not involuntarily.

This statement is incorrect. Policies regarding the use of personal mobile devices and confidentiality apply to all clients, regardless of whether they are admitted voluntarily or involuntarily. The nurse’s actions violated these policies, and the distinction between voluntary and involuntary admission does not justify the breach.

Choice E Reason:

You have violated HIPAA regulations by notifying your sibling of the client’s admission.

This is the correct response. The nurse violated HIPAA regulations by disclosing the client’s hospitalization status to their sibling without the client’s consent. HIPAA protects the privacy of individuals’ health information, and unauthorized disclosure is a serious violation that can result in legal and professional consequences.

Choice A Reason:

Somatic.

Somatic delusions involve a false belief that there is something physically wrong with one’s body, such as having a serious illness or a physical defect. In this scenario, the client’s belief that the food is poisoned does not relate to their own body but rather to an external threat, making somatic delusions an incorrect classification.

Choice B Reason:

Persecutory.

This is the correct response. Persecutory delusions, also known as paranoid delusions, involve the belief that one is being targeted, harassed, or conspired against. The client’s statement that the staff is poisoning the food reflects a belief that they are being harmed or targeted, which is characteristic of persecutory delusions. These types of delusions are the most common in schizophrenia and often involve themes of being persecuted or plotted against.

Choice C Reason:

Erotomanic.

Erotomanic delusions involve the false belief that another person, often someone of higher status, is in love with the individual. This type of delusion is not relevant to the client’s statement about the food being poisoned, as it does not involve any romantic or affectionate themes.

Choice D Reason:

Grandiose.

Grandiose delusions involve an inflated sense of one’s own importance, power, knowledge, or identity. The client’s belief about the food being poisoned does not reflect an exaggerated sense of self-importance or power, making grandiose delusions an incorrect classification for this scenario.