A nurse is caring for a client who has schizophrenia.
The client states, "The voices in my head are driving me crazy.”. Which of the following Questions should the nurse ask?

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. *.

Choice A rationale

Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.

Choice B rationale

A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.

Choice C rationale

Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.

Choice D rationale

Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.