A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

Choice A Reason:
Countertransference occurs when a healthcare provider projects their own personal feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which indicates that the nurse's personal experiences are influencing their perception of the client. This can affect the nurse's objectivity and the quality of care provided. Recognizing and managing countertransference is crucial to maintaining professional boundaries and providing unbiased care.

Choice B Reason:
Stating that the client needs to accept responsibility for their substance use is a factual statement and does not indicate countertransference. It reflects an understanding of the importance of personal accountability in the recovery process. While the tone and approach of this statement should be empathetic and supportive, it does not suggest that the nurse's personal feelings are influencing their professional judgment.

Choice C Reason:
Noting that the client generally shares their feelings during group therapy sessions is an observational statement based on the client's behavior. It does not indicate countertransference, as it is a factual observation rather than a projection of the nurse's personal experiences or feelings. This type of statement is part of objective documentation and assessment in the therapeutic process.

Choice D Reason:
Refusing a client's inappropriate request, such as asking a nurse on a date, is a professional and appropriate response. It does not indicate countertransference but rather adherence to professional boundaries. The nurse's refusal is based on maintaining a therapeutic and professional relationship, which is essential in the care of clients with substance use disorders.