A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

"The client is just like my brother who finally overcame his habit."

"The client asked me to go on a date with him, but I refused."

"The client generally shares his feelings during group therapy sessions."

"The client needs to accept responsibility for his substance use."

Answer and Explanation

The Correct Answer is A

Countertransference occurs when a staff member projects their own feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which can interfere with objective and empathetic care.

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Correct Answer is A

Explanation

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

A. WBC count 13,000/mm B. Neuropathy C. BUN 16 mg/dL D. Hypertension

Correct Answer is A

Explanation

A WBC count of 13,000/mm indicates infection, which is a common cause of delirium in older adults. Delirium is an acute confusional state that can result from various factors, such as medications, metabolic disturbances, sensory impairment, or environmental changes. Neuropathy, BUN 16 mg/dL, and hypertension are chronic conditions that do not directly cause delirium, although they may contribute to the client's overall health status.

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A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in a long-term care facility is caring for a client. The nurse should identify that which of the following conditions places the client at an increased risk for developing delirium?

Correct Answer is A

Explanation

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