A nurse is reinforcing teaching with a client about avoiding foods with tyramine. The client states, "Thank you for all of this information, but it's just not for me. I eat what I want when I want it." Which of the following stages of change is the client demonstrating?

A. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize." Social withdrawal in schizophrenia is not related to personality traits like introversion. It is often an early symptom of the disorder, preceding more pronounced psychotic features. Focusing on introversion may mislead the client and overlook the underlying pathology.
B. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." Social withdrawal is a common early sign of schizophrenia, occurring during the prodromal phase. Individuals may withdraw due to subtle cognitive changes, emotional blunting, or emerging paranoid thoughts. Recognizing these early symptoms can aid in early intervention and treatment.
C. "Were you avoiding your friend so that you could hear the voices more clearly?" This statement assumes the client was already experiencing auditory hallucinations, which is not always the case. Social isolation often predates the onset of hallucinations and delusions, making this explanation inaccurate. It may also come across as dismissive rather than informative.
D. "That is very interesting, We are not sure why people start to isolate themselves." While the exact cause of social withdrawal in schizophrenia is not fully understood, research indicates it is an early warning sign. Providing vague or uncertain information may leave the client feeling confused rather than supported in understanding their condition.

A. Inform the newly licensed nurse that they are successfully building trust and rapport. While therapeutic communication is essential, personalizing the interaction in this way crosses professional boundaries. Comparing a client to a family member can create unrealistic expectations and blur the nurse-client relationship. Maintaining professional distance ensures objective and ethical care.
B. Ask the newly licensed nurse if they are comfortable providing care to the client. While assessing a nurse’s comfort level is important, it does not address the boundary violation. The concern is not about the nurse's comfort but about maintaining professionalism in client interactions. Direct intervention is needed to correct the inappropriate statement and reinforce professional conduct.
C. Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. The statement made by the newly licensed nurse demonstrates a boundary issue rather than professionalism. Nurses should establish rapport without over-identification with clients. Documenting that the nurse maintained boundaries would be inaccurate and fail to address the issue.
D. Assign the newly licensed nurse to a different client. The statement suggests an emotional attachment that may interfere with objective care. Reassigning the nurse prevents further boundary issues and allows for education on maintaining professionalism. Ensuring appropriate nurse-client relationships promotes ethical practice and patient-centered care.