The nurse working in a custodial care facility walks into a room to administer medication and finds the client having a sexually intimate encounter with another client. The nurse's best action at this time is to:

Question

1. Make a noise to indicate that the nurse is in the room, and wait for the clients to regain composure.
2. Call Security to investigate the matter.
3. Quietly leave the room and knock on the door.
4. Notify the RN supervisor and physician.

Answer 1

3
Rationale: The nurse should leave the room and, depending on the urgency of what the nurse planned to do, either come back in a little while or knock on the door. This respects the client's privacy and prevents embarrassment. There is no need to notify anyone, and the client's need for privacy should be respected.