A client with depression assigned a 1:1 staff for close observation related to self-harm was found to have harmed themselves and sustained an injury. The nurse did not document that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

Choice A reason: Implementing interventions addresses specific needs but is not the primary goal of therapeutic communication during admission. Interventions follow after building trust, as depression and anxiety require a strong therapeutic alliance to ensure effective treatment engagement, making this a secondary priority at this stage.

Choice B reason: Teaching self-care skills is important for long-term management but not the initial communication goal. Clients with depression and anxiety need trust and emotional safety first to engage in learning, making skill-building secondary to establishing a therapeutic relationship during the admission assessment.

Choice C reason: Facilitating emotional expression is a key component of therapeutic communication but depends on a trusting relationship. Without a strong nurse-client bond, clients with depression and anxiety may resist sharing emotions, making this goal important but secondary to establishing rapport during the initial assessment.

Choice D reason: Establishing a therapeutic nurse-client relationship is the priority during admission, as it builds trust and safety, critical for clients with depression and anxiety. This foundation enables emotional expression, engagement in interventions, and skill-building, ensuring effective communication and treatment adherence, making it the primary goal in this context.

Choice A reason: Restraining and forcibly administering medication violates patient autonomy and ethical principles, potentially escalating agitation in psychosis. It risks physical harm and legal issues, as forced medication requires specific legal orders (e.g., involuntary commitment). Non-invasive approaches like negotiation or assessing refusal reasons are safer and more ethical.

Choice B reason: Stating that refusal prevents improvement is coercive and undermines autonomy. It fails to explore reasons for refusal, such as side effect concerns or psychosis-related mistrust, which are common in severe psychosis. This approach may damage trust and hinder therapeutic alliance, making it inappropriate as an initial action.

Choice C reason: Accepting the client’s refusal respects autonomy while prioritizing safety, critical in psychosis where agitation is common. This allows exploration of refusal reasons (e.g., paranoia) and alternative interventions, maintaining a therapeutic environment. Monitoring ensures no immediate harm, making this the most ethical and safe initial response.

Choice D reason: Obtaining a discharge order for nonadherence is premature and inappropriate, as refusal does not warrant immediate discharge. Psychosis requires ongoing assessment and management, and discharge could exacerbate symptoms or risk harm, making this action contrary to the goal of stabilizing the client’s mental health.