While the nurse is measuring blood pressure, the client lifts his hand

While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurse’s breast. What should the nurse do about this behavior?

1. Ignore the fondling.
2. Move the client’s hand away.
3. Refocus the client on appropriate behavior.
4. Tell the client to stop performing the behavior.
5. Communicate that the behavior is not acceptable.

ANSWER

Correct Answer: 2, 3, 4, 5

Rationale: The nurse needs to set limits with the client, and ignoring the behavior would communicate that it is acceptable.