A male nurse enters the room of a female client to obtain the client's vital signs. The client's spouse appears uncomfortable with the nurse and moves closer to the client. Which action by the nurse is most appropriate?
A) Ask a female staff member to obtain the client's vital signs.
B) Ask the client's spouse to leave the client's room.
C) Perform the intervention without discussion.
D) Explain the procedure to both the client and client's family member.
Answer: D
The nurse should explain the procedure to both the client and the client's family member. Asking another staff member to obtain the client's vital signs is inappropriate. The spouse does not need to leave the client's room. Performing an intervention without first discussing it and asking for permission may be interpreted as assault.
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