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Referring the client to a rape crisis hotline is an important part of the long-term support plan, but it is not the initial nursing action. At the moment of presentation, the client is likely in acute psychological distress and may not be ready to process external resources. Immediate emotional stabilization and safety are prioritized before referrals.

Encouraging the client to file charges immediately may be perceived as coercive and can further traumatize the individual. Legal decisions should be client-led and made when the person feels emotionally safe and supported. Pushing for legal action prematurely can compromise therapeutic rapport and the client's sense of control.

Performing a nursing history and physical is necessary, especially for forensic and medical documentation. However, it should only be done after establishing trust and emotional safety. Jumping into assessments without first addressing the client’s emotional state can be retraumatizing and may hinder cooperation.

This statement pathologizes the client’s behavior without sufficient evidence. While avoidance can be a maladaptive coping strategy, returning to work does not inherently indicate avoidance. It may reflect resilience or a healthy attempt to regain normalcy. Making assumptions can alienate the client and hinder therapeutic communication.

Suggesting that it may be too early to return to work imposes a timeline on grief that is not evidence-based. Grieving is highly individualized, and many people find comfort in routine. This statement risks invalidating the client’s experience and may discourage adaptive coping.

Telling the client they cannot work effectively and should finish grieving first is both inaccurate and dismissive. Grief does not have a defined endpoint, and many individuals function well while grieving. This statement undermines the client’s self-assessment and can be perceived as judgmental.

Reviewing life and discussing death are signs of acceptance and psychological processing. These behaviors are consistent with the tasks of dying, such as life review and meaning-making. They do not indicate denial or maladaptive coping, and thus do not require urgent intervention.

Expressing a desire to live life to the fullest reflects a positive coping strategy. It suggests that the client is engaging with the time remaining in a meaningful way. This attitude supports emotional well-being and does not signal a need for corrective intervention.

Hoping for a peaceful and dignified death is a realistic and healthy expectation for someone with terminal illness. It reflects acceptance and a desire for comfort-focused care. This statement aligns with palliative goals and does not indicate psychological distress.

Absence of grief refers to a lack of emotional response following a loss. This does not apply here, as the woman is clearly expressing sadness and emotional conflict. Her tears and reflection on future desires for children indicate active grieving.

Complicated grief involves prolonged or intense grief that interferes with functioning. While the woman is grieving, there is no indication that her grief is prolonged, disabling, or beyond the expected emotional response for her situation. Therefore, this choice does not fit the scenario.

Anticipatory grief occurs before an expected loss, such as grieving a terminally ill loved one before death. This woman is grieving a loss that has already occurred, not one she is anticipating, so this type of grief is not applicable.

Physiologic loss refers to the loss of physical function or body parts, such as vision or mobility. Witnessing a traumatic event does not involve physical loss to the child, so this option is incorrect.

Loss of self-esteem involves damage to one’s self-worth, often due to failure, rejection, or humiliation. While trauma can affect self-esteem over time, the immediate loss in this scenario is related to safety, not self-perception.

Loss related to self-actualization refers to the inability to achieve personal goals or potential. This type of loss is more abstract and long-term. The child’s immediate response to witnessing violence is rooted in fear and insecurity, not blocked aspirations.

While documentation is essential, recording the refusal without understanding the reason or notifying the primary nurse is incomplete. It may lead to missed opportunities for intervention or compromise client safety.

Telling the client that refusal is not permitted violates ethical and legal standards. Clients have autonomy and the right to refuse treatment. Coercion undermines trust and can be considered abusive.

This response is unprofessional and manipulative. It prioritizes the student’s academic concerns over the client’s rights and well-being. Such statements can damage therapeutic rapport and are inappropriate in clinical practice.

Gravely disabled refers to a person who cannot meet basic needs such as food, shelter, or hygiene due to mental illness. There is no indication in the scenario that the client is unable to care for himself, so this criterion does not apply.

Dangerous to self involves behaviors or statements indicating self-harm or suicidal ideation. The client expresses paranoia but does not indicate intent to harm himself.

The client’s behavior and mental state suggest he may pose a risk to others. Therefore, stating that he does not meet any criteria is incorrect.

Violating a nurse’s boundaries may be inappropriate or unethical, but it does not legally justify breaching confidentiality. Legal obligations are based on safety and risk, not interpersonal dynamics.

Aggression alone does not warrant breaching confidentiality unless it includes specific threats to others. General aggression may be managed within the therapeutic setting without violating privacy.

Threatening behavior must be assessed for specificity and risk. Not all threats justify breaching confidentiality. Only threats to identifiable individuals or groups with a credible risk require legal action.

Confidentiality remains intact during involuntary admission, except in cases where safety is at risk. The client’s health information is still protected under HIPAA and other privacy laws.

Clients under involuntary admission are entitled to periodic treatment reviews to ensure that continued hospitalization is justified and that their rights are protected.

Clients retain the right to choose providers unless their condition requires specific interventions. This right may be limited in emergencies but is not automatically revoked.

Attention-seeking behavior is typically deliberate and goal-oriented. In this case, the client is alone and speaking to unseen stimuli, which is more consistent with psychotic symptoms than manipulative behavior.

While schizophrenia may be the underlying diagnosis, the nurse cannot confirm this based on one observation. The behavior described is a symptom, not a diagnosis.

Multiple personality disorder, now known as dissociative identity disorder, involves distinct identity states, not necessarily talking to oneself in response to hallucinations. This diagnosis is rare and cannot be inferred from the described behavior.