A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.

Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.

Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.

Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.

Choice A reason: Administering the medication via IM injection against the client's will can be considered a violation of the client's rights, especially in the context of mental health care where consent and autonomy are highly valued. Involuntary treatment, including medication administration, should only be considered in situations where the client poses an immediate risk to themselves or others, which is not indicated in the scenario provided.

Choice B reason: Offering the medication at the next scheduled dose time respects the client's current decision to refuse the medication while also maintaining the prescribed treatment plan. It allows time for the client to reconsider their decision and provides an opportunity for the nurse to engage in further discussion about the benefits and importance of the medication, potentially addressing any concerns or fears the client may have.

Choice C reason: Informing the client that they do not have the right to refuse medication is incorrect and unethical. Patients have the right to informed consent, which includes the right to refuse treatment. This is particularly important in mental health care, where respecting the client's autonomy and rights is essential for building trust and promoting recovery.

Choice D reason: Implementing consequences for refusing medication is coercive and can damage the therapeutic relationship between the nurse and the client. It may also lead to increased resistance and distrust from the client, which can negatively impact their overall care and treatment outcomes.