A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

Choice A rationale:

Fidelity refers to the principle of being loyal, faithful, and keeping promises. It does not specifically relate to providing accurate information about treatment effects. In this scenario, the nurse is discussing the potential adverse effects of a treatment, which falls under the domain of providing accurate and truthful information to the client.

Choice B rationale:

Beneficence is the ethical principle of doing good and promoting the well-being of the patient. While educating the client about potential adverse effects is a form of beneficence, the specific principle demonstrated in this scenario is veracity, which is the duty to tell the truth. The nurse is being truthful about the potential side effect (lightheadedness) while clarifying that it should not affect memory.

Choice C rationale:

Veracity is the ethical principle of truth-telling. In this scenario, the nurse is demonstrating veracity by providing honest and accurate information to the client about the potential adverse effects of transcranial magnetic stimulation. By being truthful, the nurse upholds the ethical principle of veracity.

Choice D rationale:

Autonomy refers to the principle of respecting the patient's right to make decisions about their own healthcare. While respecting autonomy is important, the nurse's action in this scenario specifically pertains to providing accurate information (veracity) rather than solely focusing on the client's decision-making autonomy.

Choice A rationale:

Initiating IV access on the palmar side of the client's wrist is not recommended. This area has many delicate structures and is prone to complications such as nerve damage. Choosing a safer, larger vein proximal to the wrist is a better practice.

Choice B rationale:

Inserting a larger gauge IV catheter is not necessary unless the client's condition or prescribed therapy specifically requires it. Using an unnecessarily large catheter can cause discomfort and increase the risk of complications, such as phlebitis.

Choice C rationale:

Choosing the client's dominant arm for IV access whenever possible is not a universally appropriate guideline. The choice of the arm should depend on the condition of the veins and the individual patient's circumstances. The nurse should assess both arms and choose the one with the most suitable and accessible veins.

Choice D rationale:

Selecting a site proximal to previous venipuncture sites is the correct action. Repeated venipuncture in the same area can cause phlebitis and compromise the integrity of the veins. Selecting a new site proximal to previous punctures helps to preserve vein health and reduce the risk of complications.