A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.

B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."

This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.

C. "Because you are a minor, I have to share any information that I feel is important with your parents."

While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.

"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."

Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.