A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?

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.

Encouraging client feedback about their satisfaction with the facility experience is related to communication and patient-centered care, but it's not directly addressing the client's autonomy in making decisions about their own care or treatment.

B) Explaining unit rules and policies regarding unacceptable behaviors:

Explaining unit rules and policies is important for maintaining a safe and therapeutic environment, but it's more about providing information and setting expectations rather than addressing the client's autonomy.

C) Supporting the client's wish to refuse prescribed medications.

Explanation:

Autonomy is the ethical principle that emphasizes an individual's right to make decisions about their own care and treatment. In the context of healthcare, respecting autonomy means that healthcare professionals should honor a patient's decisions as long as they are informed and capable of making those decisions. By supporting the client's wish to refuse prescribed medications, the nurse is respecting the client's autonomy and allowing them to have control over their own treatment decisions.

D) Making sure the client understands expectations for client participation:

Ensuring that the client understands expectations for participation is important for collaboration in their care, but it's not directly related to the client's autonomous decision-making about their treatment.