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 asked me to go on a date with him, but I refused.”.

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

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

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

Answer and Explanation

The Correct Answer is C

Choice A rationale:

"The client asked me to go on a date with him, but I refused.”. This statement does not demonstrate countertransference. It is a clear example of professional boundaries being maintained, as the staff nurse refused the client's request for a date, which is appropriate in the context of the nurse-client relationship.

Choice B rationale:

"The client needs to accept responsibility for his substance use.”. This statement does not indicate countertransference. It reflects a common and appropriate therapeutic goal, which is to help clients take responsibility for their actions and substance use disorder.

Choice C rationale:

"The client is just like my brother who finally overcame his habit.”. This statement represents countertransference. Countertransference occurs when a healthcare professional's emotions, attitudes, or past experiences influence their perceptions and interactions with a client. In this case, the staff nurse is making a connection between the client and their own brother, suggesting a personal bias based on past experiences. This can hinder the staff nurse's ability to provide objective care.

Choice D rationale:

"The client generally shares his feelings during group therapy sessions.”. This statement does not demonstrate countertransference. It is a straightforward observation of the client's behavior during group therapy sessions and does not involve any emotional or personal bias on the part of the staff nurse.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining consent from the client's family member is not the appropriate action in this scenario. The client has the right to make decisions about their own medical treatment, and the consent should come from the client themselves, not a family member.

Choice B rationale:

Informing the client that they have the legal right to refuse treatment at any time is the correct action. Informed consent is a fundamental principle of medical ethics, and the nurse should respect the client's autonomy and right to make decisions about their own healthcare.

Choice C rationale:

Requesting another nurse to review the procedure with the client may be helpful in providing additional information and support, but it does not address the client's right to refuse treatment. The primary responsibility is to ensure that the client is aware of their right to refuse.

Choice D rationale:

Encouraging the client to have the procedure goes against the principle of respecting the client's autonomy and right to make their own decisions about their healthcare. The nurse should not pressure the client into having the procedure.

A. Bowel sounds. B. Blood pressure. C. Oxygen saturation. D. Pupil response.

Correct Answer is B

Explanation

The correct answer is choice B. Blood pressure.

Choice A rationale:

Bowel sounds. While assessing bowel sounds can be a part of a comprehensive physical assessment, it is not directly related to the interaction between phenelzine and pepperoni pizza. Phenelzine is a monoamine oxidase inhibitor (MAOI) used to treat depression. It does not have a known interaction with the digestive system that would necessitate monitoring bowel sounds after eating pepperoni pizza.

Choice B rationale:

Blood pressure. This is the correct choice. Phenelzine can interact with tyramine, a substance found in certain foods like pepperoni. This interaction can lead to a hypertensive crisis, a sudden and severe increase in blood pressure. Therefore, after the client reports eating pepperoni pizza, the nurse should assess the client’s blood pressure to monitor for this potential reaction.

Choice C rationale:

Oxygen saturation. While oxygen saturation is an important vital sign, it is not directly affected by the interaction between phenelzine and pepperoni pizza. Therefore, it would not be the most relevant assessment in this situation.

Choice D rationale:

Pupil response. Pupil response can be an indicator of neurological status, but it is not directly related to the interaction between phenelzine and pepperoni pizza. Therefore, it would not be the most relevant assessment in this situation.

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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 has an anxiety disorder and is scheduled for a procedure.The client informs the nurse that they do not want to have the procedure.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

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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?