A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

The correct answer is Choice D.

Choice A rationale: Requesting additional information about the caller's relationship to the client does not ensure the caller's identity is verified, and it could still result in a breach of confidentiality.

Choice B rationale: Providing a general update about the client's condition over the telephone is not appropriate, as it could breach the client's confidentiality.

Choice C rationale: Referring the family member to the client's provider for the update respects confidentiality and ensures that information is only provided to authorized individuals, maintaining the client's privacy.

Choice D rationale: Encouraging the family member to contact the client directly for information ensures that the client has control over their own information and maintains confidentiality. This action respects the client's privacy and autonomy.

Choice A rationale:

Managing conflict within the group is an important skill, but it is more appropriate for the working phase of group therapy. During the orientation phase, the focus is on establishing trust, setting group norms, and creating a safe environment. Conflict resolution skills become more relevant as the group progresses.

Choice B rationale:

Encouraging the use of problem-solving skills is essential in group therapy, but it is a skill that is developed during the working phase. During the orientation phase, the nurse focuses on building rapport, creating a comfortable atmosphere, and explaining the purpose and goals of the group.

Choice C rationale:

Maintaining the group's focus on identified issues is a crucial aspect of the orientation phase. The nurse should guide the discussion to ensure that participants understand the purpose of the group and stay on topic. This helps in establishing clear goals and expectations for the group sessions.

Choice D rationale:

Establishing a rapport with group members is a primary goal of the orientation phase. Building trust and a therapeutic relationship with the adolescents creates a supportive environment where they feel comfortable sharing their experiences and emotions. A strong rapport enhances the effectiveness of the support group.