A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?

A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.

B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."

This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.

C. "Because you are a minor, I have to share any information that I feel is important with your parents."

While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.

"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."

Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.

While offering female assistive personnel for personal hygiene care is one option, it doesn't necessarily address the larger concern of the client's discomfort with a male nurse in her care team. The nurse manager's response should address the client's overall care and interactions.

B) "Your doctor is a man, so it seems like this should not be a problem."

Comparing the client's situation to the gender of the doctor might not be perceived as sensitive or supportive. The client's comfort with different members of the care team can vary, and it's important to address her concerns directly.

C) "I can review the assignments and arrange for a female nurse to care for you."

Explanation:

Respecting a patient's preferences and comfort is an important aspect of patient-centered care. If the female client expresses discomfort with a male nurse providing care due to her traumatic experience, it's appropriate for the nurse manager to accommodate her request if feasible. Changing the assignment to ensure that a female nurse provides care respects the client's wishes and helps create a more supportive and comfortable environment.

D) "The nurse assigned to care for you is very capable and cares for other women in this situation."

While it's important to emphasize the capabilities of the nurse, this response does not directly address the client's expressed discomfort with a male nurse. It's crucial to prioritize the client's feelings and concerns in this situation.