The nurse is assisting with patient data collection in a clinic. The nurse is assigned to a young female patient who has an older male friend present at her bedside. The patient is nervous, timid, very thin, and with poor hygiene and lets the friend answer all of the nurse's questions. What actions should the nurse take?

Explanation:

A. Nonmaleficence: This ethical principle emphasizes the duty of healthcare professionals to avoid causing harm to patients. It involves refraining from actions that could potentially harm the patient, whether physical, emotional, psychological, or social. Nonmaleficence is about acting in a way that promotes the well-being and safety of patients and avoiding actions that could result in harm or injury.

B. Fidelity: Fidelity pertains to the faithfulness, loyalty, and honoring of commitments and promises made to patients. It involves maintaining trust and being truthful in interactions with patients.

C. Beneficence: Beneficence involves the obligation to do good and promote the well-being of patients. It includes actions aimed at benefiting patients, such as providing effective treatments, interventions, and support to improve their health outcomes and quality of life.

D. Justice: Justice relates to fairness and equality in healthcare. It involves the fair distribution of resources, allocation of care, and treatment decisions without discrimination or bias, ensuring that all patients receive equitable care based on their needs and circumstances.

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.