A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition.
Which of the following actions should the nurse take to maintain the client's confidentiality?

 

Choice A rationale:

Asking the client directly about the hallucinations is essential in understanding the nature and content of the hallucinations. This information is crucial for the nurse to assess the client's mental state accurately and plan appropriate interventions. Direct communication helps establish trust and rapport with the client, making them more likely to share their experiences.

Choice B rationale:

Avoiding eye contact can create a sense of disconnection and may increase the client's anxiety. Establishing eye contact, on the other hand, communicates empathy and attentiveness, which are essential in therapeutic communication.

Choice C rationale:

Encouraging the client to lie down in a quiet room might not be the most appropriate action, as it does not address the hallucinations directly. It's important to address the hallucinations and help the client cope with them effectively.

Choice D rationale:

Referring to the hallucinations as if they are real might validate the client's experience but can also perpetuate the hallucinations. The nurse should acknowledge the client's feelings without reinforcing the false beliefs. Providing reality-based perspectives and encouraging the client to explore the origin of these hallucinations can be more beneficial.

The correct answer is Choice C, the system is working properly.

Choice A rationale: The lung has re-expanded is incorrect. If the lung has re-expanded, there would be no tidaling in the water seal chamber, as the pleural space would be restored to its normal negative pressure.Tidaling indicates that there is still air or fluid in the pleural space that needs to be drained

Choice B rationale: There is a loop of tubing below the drainage system is incorrect. A loop of tubing below the drainage system would not cause tidaling in the water seal chamber, but it could cause fluid accumulation in the tubing, which could impair the drainage and increase the risk of infection.The tubing should be straight and free of kinks or loops

Choice C rationale: The system is working properly is correct. Tidaling in the water seal chamber means that the water level rises and falls with the patient’s respirations. This is normal and expected, as it indicates that the chest tube is patent and connected to the pleural space, and that the drainage system is airtight and preventing air or fluid from entering the pleural space.Tidaling should stop when the lung is fully re-expanded or the chest tube is clamped

Choice D rationale: The tubing is partially obstructed by clots is incorrect. If the tubing is partially obstructed by clots, there would be no tidaling in the water seal chamber, as the chest tube would not be able to drain the air or fluid from the pleural space. The water level in the water seal chamber would be stagnant, and the patient may experience respiratory distress.The tubing should be checked regularly for clots and milked gently if needed