A nurse in a mental health facility is interviewing a newly admitted client who is related to the nurse's neighbor. The nurse should identify that which of the following must occur when establishing a therapeutic nurse-client relationship?
The nurse maintains confidentiality unless the client's safety is compromised.
The nurse seeks to spend extra time specifically with the client each day.
The client sees the nurse as an authority figure.
The client regards the nurse as a friend.
The Correct Answer is A
A. The nurse maintains confidentiality unless the client's safety is compromised:
Explanation: Maintaining confidentiality is a fundamental principle in nursing practice. Nurses are ethically and legally obligated to keep client information confidential, ensuring that the client's privacy is respected. Confidentiality builds trust between the nurse and the client, encouraging open communication. However, confidentiality can be breached if the client's safety is at risk, such as if they express suicidal or homicidal thoughts, indicating the need for intervention to ensure their well-being.
B. The nurse seeks to spend extra time specifically with the client each day:
Explanation: While it's important for nurses to spend adequate time with each client, seeking to spend extra time specifically with one client may create imbalances in care distribution. Nurses should strive to provide equitable care to all clients, addressing their needs based on assessments and care plans. Special attention to one client could lead to feelings of favoritism or neglect among other clients, affecting the therapeutic environment.
C. The client sees the nurse as an authority figure:
Explanation: Clients often view nurses as authority figures due to their expertise and role in healthcare. This perception can facilitate a therapeutic relationship, as clients may trust the nurse's guidance and care. However, this should be balanced with empathy and understanding to create a supportive and therapeutic environment.
D. The client regards the nurse as a friend:
Explanation: While a therapeutic nurse-client relationship aims for trust and rapport, it is not a friendship. The nurse maintains professional boundaries to provide objective care without personal bias. Friendship implies a level of personal involvement that can compromise the nurse's ability to make objective clinical decisions. A therapeutic relationship is built on trust, respect, empathy, and clear professional boundaries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will learn how to voluntarily control my blood pressure and heart rate."
This statement indicates the client might be referring to techniques such as biofeedback or relaxation exercises that involve controlling physiological responses consciously. While these are relaxation techniques, they are not specifically cognitive reframing. Cognitive reframing focuses on changing negative thought patterns.
B. "I will practice replacing negative thoughts with positive self-statements."
This statement accurately reflects the concept of cognitive reframing. It involves identifying negative or unhelpful thoughts and consciously replacing them with positive, empowering, or rational thoughts. This technique is widely used in cognitive-behavioral therapy (CBT) to help individuals manage stress, anxiety, and various mental health issues.
C. "I will focus on a mental image while concentrating on my breathing."
This statement describes a relaxation technique where individuals visualize a calming image and synchronize their breathing with this mental image. While this practice is beneficial for relaxation, it is not cognitive reframing. Cognitive reframing specifically deals with changing the content of thoughts, not necessarily focusing on mental imagery.
D. "I will progressively relax each of my muscle groups when feeling stressed."
This statement describes a relaxation technique known as progressive muscle relaxation. It involves tensing and then relaxing different muscle groups to reduce physical tension and stress. While this technique is excellent for relaxation, it is not cognitive reframing. Cognitive reframing pertains to changing thoughts, not physical sensations.
Correct Answer is B
Explanation
A. Seat the client at a dining table with six or more residents:
People with Alzheimer's disease often experience sensory overload in crowded and noisy environments. Large dining tables with multiple residents can be overwhelming for someone with Alzheimer's, leading to increased confusion and discomfort. It's more beneficial to seat them in a smaller, quieter setting to reduce stress and promote a more relaxed dining experience.
B. Use symbols to assist the client in locating rooms:
Individuals with Alzheimer's disease frequently have difficulties with memory and orientation. Using symbols or visual cues can aid them in understanding and remembering locations, reducing confusion and promoting independent movement within the facility or home.
C. Provide the client with several choices for meal selection:
While offering choices is generally a good practice, individuals with Alzheimer's disease may find it challenging to process too many options. Providing limited, clear choices can help prevent decision-making difficulties and reduce frustration. Too many choices can overwhelm them, leading to indecision and potential agitation.
D. Give complete directions before starting client care:
Providing complete and lengthy directions can overwhelm individuals with Alzheimer's disease. They may have difficulty processing complex instructions due to cognitive impairment. It's more effective to give simple, step-by-step directions and provide assistance as needed. Additionally, using gentle reminders and cues can support their understanding and cooperation without overwhelming them with too much information at once.
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