A nurse is planning care for a client who has adjustment disorder following a traumatic below-the-knee amputation. Which of the following actions should the nurse include?

A. Identify the goals that the client achieved during the relationship:
This activity typically occurs during the termination or closure phase of the nurse-client relationship. It involves reflecting on the progress made by the client toward their goals. During this phase, both the nurse and the client review the goals set at the beginning of the therapeutic relationship and identify which ones have been achieved. This helps in evaluating the effectiveness of the therapeutic interventions.

B. Assist the client to make changes in her behavior:
This action is a central aspect of the working phase. In this phase, the nurse and client collaboratively work on addressing the client's issues. The nurse provides support, guidance, and appropriate interventions to help the client modify their thoughts, emotions, and behaviors. The goal is to facilitate positive changes and promote the client's mental and emotional well-being.

C. Inform the client about confidentiality issues:
Discussing confidentiality is essential at the beginning of the therapeutic relationship, during the orientation phase. The nurse informs the client about the limits of confidentiality, explaining what information will be kept confidential and under what circumstances confidentiality might need to be breached (such as when there is a risk of harm to the client or others). This discussion helps establish trust and clear boundaries within the relationship.

D. Discuss the client's responsibilities for the relationship:
Clarifying the client's responsibilities occurs primarily during the orientation phase. In this phase, the nurse outlines what the client can expect from the therapeutic relationship and what is expected from them. This includes discussing the client's active participation in the process, their commitment to attending sessions, being open and honest, and actively engaging in therapeutic activities and homework assignments.

A. Withholding a prescribed medication that is causing adverse effects for the client
The principle of nonmaleficence, often summarized as "do no harm," emphasizes the nurse's duty to prevent harm and to remove existing harm. If a medication prescribed to a client is causing adverse effects, the nurse should withhold the medication to prevent harm to the client.

B. Educating the client about legal rights concerning treatment
Educating the client about their legal rights falls under providing information and ensuring the client's autonomy but does not directly address the principle of non-maleficence.

C. Providing the client with quality care regardless of ability to pay for treatment
Providing quality care regardless of the client's ability to pay is an ethical practice, but it aligns more with the principles of justice and beneficence rather than nonmaleficence.

D. Being truthful with the client about the manifestations of withdrawal
Being truthful and providing accurate information to the client about withdrawal symptoms is crucial, but it doesn't directly address the principle of nonmaleficence.