A nurse is caring for an adult client who has a developmental disability. The client requires an emergency appendectomy, and the staff cannot reach the appointed guardian. Which of the following is an appropriate action for the nurse to take?

Rationale:

A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.

B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.

C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.

D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.

Rationale:

A. This response dismisses the concerns of the assistant personnel and is not supportive.

B. This response minimizes the assistant personnel's concerns and does not acknowledge their feelings.

C. This response acknowledges the assistant personnel's concerns and opens the door for further discussion.

D. This response does not address the assistant personnel's concerns and suggests a formal complaint as the only solution. It is not supportive or collaborative.