A client diagnosed with Illness Anxiety Disorder is prescribed clonazepam for underlying anxiety. Of the following, which is of utmost importance when caring for this client?

Choice A Reason:

This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B Reason:

While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C Reason:

This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D Reason:

Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.

Choice A Reason:

The client’s perception of the event, the availability of supports, and the availability of adequate coping mechanisms.

This is the correct response. A client’s perception of a stressful event plays a crucial role in determining whether they experience a crisis. If the client views the event as overwhelming and beyond their ability to cope, they are more likely to experience a crisis. Additionally, the availability of social supports, such as family, friends, and community resources, can provide emotional and practical assistance, reducing the likelihood of a crisis. Adequate coping mechanisms, such as problem-solving skills, emotional regulation, and stress management techniques, also play a significant role in helping the client manage stress effectively.

Choice B Reason:

Previous experiences, the availability of medication, and the desire to cope.

While previous experiences can influence how a client responds to stress, they are not the sole determinants of whether a crisis will occur. The availability of medication can help manage symptoms of stress or anxiety, but it does not address the underlying perception of the event or the availability of supports. The desire to cope is important, but without adequate coping mechanisms and support, it may not be sufficient to prevent a crisis.

Choice C Reason:

Faith in the psychiatrist, the availability of financial resources, and previous level of functioning.

Faith in the psychiatrist and the availability of financial resources can provide some support, but they do not directly address the client’s perception of the event or their coping mechanisms. Previous level of functioning is important, but it is not the primary factor in determining whether a crisis will occur. The client’s current perception and available supports are more critical in this context.

Choice D Reason:

The time of day, the client’s mood, and the availability of escape from the situation.

The time of day and the client’s mood can influence their immediate response to stress, but they are not the primary determinants of whether a crisis will occur. The availability of escape from the situation may provide temporary relief, but it does not address the underlying perception of the event or the availability of supports and coping mechanisms.