A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?
Set limits for the relationship.
Engage in affectionate interactions with the client.
Promote the use of transference by the client.
Instruct the client on how he should behave.
The Correct Answer is A
The correct answer is choice A: Set limits for the relationship.
Choice A rationale:
Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance. Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.
Choice B rationale:
Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.
Choice C rationale:
Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.
Choice D rationale:
Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The client taking an overdose of the medication is unlikely to be the cause of the symptoms. Disulfiram (Antabuse) is a medication used to treat alcohol dependence by causing adverse effects when alcohol is consumed. However, an overdose would not result in severe nausea and vomiting as described.
Choice B rationale:
Experiencing common side effects of the medication is a possibility, but severe nausea and vomiting are not typical side effects of disulfiram. The medication's primary purpose is to induce unpleasant effects when alcohol is consumed, not to cause severe gastrointestinal symptoms.
Choice C rationale:
Demonstrating an allergic response to the medication could potentially cause various symptoms, but severe nausea and vomiting are not commonly associated with allergies to disulfiram. Allergic reactions often manifest as skin rashes, itching, and respiratory symptoms, which are not described in this scenario.
Choice D rationale:
The correct choice. Disulfiram works by inhibiting alcohol metabolism, leading to the accumulation of acetaldehyde, a toxic substance, when alcohol is consumed. This buildup of acetaldehyde results in unpleasant symptoms like severe nausea, vomiting, headache, and flushing. Since the client has recently started taking disulfiram and reports experiencing severe nausea and vomiting after discontinuing the medication, it is most likely that the client consumed alcohol while taking the medication, triggering the adverse reaction.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a potential physical symptom of alcohol withdrawal. When alcohol-dependent individuals suddenly stop or reduce their alcohol intake, it can lead to increased sympathetic nervous system activity, resulting in elevated heart rate.
Choice B rationale:
Tremors (shakes) are common during alcohol withdrawal due to the suppression of the central nervous system by alcohol. Abrupt cessation of alcohol can lead to overactivity in the nervous system, resulting in tremors.
Choice C rationale:
Hallucinations can occur during alcohol withdrawal and are usually visual or tactile in nature. These hallucinations are often referred to as alcoholic hallucinosis and can be distressing for the individual experiencing them.
Choice E rationale:
Seizures can be a severe consequence of alcohol withdrawal. Known as alcohol withdrawal seizures, these episodes can occur within the first 48 hours after cessation of heavy alcohol consumption and are attributed to the hyperexcitability of the central nervous system.
Choice D rationale:
Hypotension (low blood pressure) is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal often leads to an increase in blood pressure and heart rate due to the hyperactivity of the sympathetic nervous system.
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