A nurse is preparing a client's body for a postmortem family viewing.

Which of the following actions should the nurse take?

The response acknowledges the client's feelings and validates their experience without reinforcing or denying the delusion. It demonstrates empathy and invites further exploration of the client's concerns. Open-ended statements like this can encourage the client to express their thoughts and feelings, allowing for therapeutic communication and building trust between the client and nurse.
A. "The psychiatric staff is not FBI. They are here to help you." This response directly contradicts the client's belief and may lead to increased distrust or resistance. It is important to avoid directly challenging delusions or imposing one's own reality on the client, as it can escalate their distress.
C. "What makes you think the staff is following you?" While this response seeks more information, it may inadvertently reinforce or amplify the client's delusion. It could be interpreted as confirmation or validation of their belief, potentially increasing anxiety or paranoia.
D. "Why do you feel the staff is the FBI?" This response also seeks more information, but it may come across as challenging or dismissive. It could potentially trigger defensiveness or hostility in the client. It is important to approach the client's beliefs with empathy and respect rather than questioning or interrogating them.

When providing a change-of-shift report, it is important to do so in a private and secure area away from public spaces. Sharing client information outside the client's room helps maintain confidentiality and prevents unauthorized individuals from overhearing sensitive information. Discussions about a client's prognosis should be limited to the appropriate healthcare professionals involved in the client's care. Sharing this information with an assistive personnel who is not directly involved in the client's care breaches confidentiality.

Displaying a client's diagnosis on a message board in a public area breaches confidentiality. It is essential to respect and protect a client's privacy by avoiding the unnecessary disclosure of sensitive information.

Proper disposal of documents containing client information is crucial to maintain confidentiality. Discarding worksheets with client information in a wastebasket without ensuring they are securely destroyed or shredded poses a risk of unauthorized access to sensitive information.