A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

Choice A reason:
Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining order and safety within the facility. However, this action is more about setting boundaries and expectations rather than supporting the client’s autonomy. Autonomy involves respecting the client’s right to make their own decisions, which is not directly addressed by merely explaining rules.
Choice B reason:
Supporting the client’s wish to refuse prescribed medications demonstrates respect for the client’s autonomy. Autonomy is the ethical principle that recognizes the right of individuals to make informed decisions about their own care. By supporting the client’s decision to refuse medication, the nurse acknowledges and respects the client’s right to make choices about their treatment, even if those choices differ from medical advice.
Choice C reason:
Making sure the client understands expectations for client participation is essential for clear communication and effective treatment planning. However, this action is more about ensuring compliance and understanding rather than promoting autonomy. While it is important for clients to understand what is expected of them, this does not necessarily empower them to make their own decisions.
Choice D reason:
Encouraging client feedback about satisfaction with the facility experience is a valuable practice for improving care and ensuring that clients feel heard. However, this action focuses on gathering feedback rather than directly supporting the client’s autonomy. While it contributes to a client-centered approach, it does not specifically address the client’s right to make independent decisions about their care.

Choice A reason:

Developing a flexible crisis intervention plan is essential in managing a client’s anxiety crisis. Flexibility allows the nurse to adapt the plan to the client’s changing needs and circumstances, ensuring that the interventions remain effective and appropriate.

Choice B reason:

Identifying the cause of the anxiety is crucial for effective intervention. Understanding the underlying factors contributing to the client’s anxiety helps the nurse address the root of the problem and develop targeted strategies to alleviate the client’s distress.

Choice C reason:

Validating the client’s feelings is an important therapeutic technique. It helps the client feel understood and supported, which can reduce anxiety and build trust between the client and the nurse. Validation acknowledges the client’s emotions without judgment.

Choice D reason:

Establishing rapport with the client is fundamental in any therapeutic relationship. Building rapport fosters trust and open communication, which are essential for effective crisis intervention. A strong therapeutic relationship can help the client feel more secure and supported.

Choice E reason:

Avoiding eye contact is not recommended as it can be perceived as dismissive or disinterested. Maintaining appropriate eye contact shows that the nurse is engaged and attentive, which can help reassure the client and reduce anxiety. It is important to balance eye contact to avoid making the client feel uncomfortable.