When a nurse responds to a client's call light, the client tells the nurse that his watch is missing.

He states that he left it in the drawer of his bedside table, and now it is not there.

Later, the nurse sees an assistive personnel (AP) taking a man's watch from her pocket and putting it in her purse.

Which of the following actions should the nurse take?

Choice A rationale

This statement is dismissive of the client's concern and incorrectly implies that medication is a required part of rest and recovery. The client has the right to refuse medication, and this statement does not address their fears about being forced to take drugs. Providing false reassurance or being dismissive can damage the therapeutic nurse-client relationship and increase the client's anxiety.

Choice B rationale

This is an inappropriate response as it places the burden of explanation on the client and can be perceived as an accusatory question. Therapeutic communication requires the nurse to validate the client's feelings and provide accurate information, not to question their rationale.

The nurse should address the client's fear directly and reassure them about their rights.

Choice C rationale

This statement is correct because it upholds the client's rights. Under involuntary admission, a client retains the right to refuse psychotropic medication unless a court order has been obtained or there is an emergency situation where the client is a danger to themselves or others. The nurse's statement respects the client's autonomy and provides accurate information about their legal rights.

Choice D rationale

This statement is legally and ethically incorrect. Even with an involuntary admission, a client retains their fundamental rights, including the right to refuse treatment. Forcing a client to accept treatment against their will is a violation of their autonomy and can only be done in specific, legally defined circumstances, such as an emergency or through a court order. This response is coercive and non-therapeutic. *.

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. *.