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 C
Explanation
A. "What have you done to change your situation?"
This response can come off as accusatory and might make the client feel judged. It's not the most therapeutic response in this situation.
B. "You should remove yourself from this situation now."
While removing oneself from a harmful situation is generally good advice, it might not be practical or safe in the heat of the moment. Moreover, this response doesn't address the underlying emotional distress the client is expressing.
C. “Are you thinking about harming yourself?"
This response directly assesses the client's suicidal ideation. It's essential to ask direct questions about self-harm when a person expresses feelings of hopelessness, as it provides an opportunity for the client to talk about their thoughts and feelings and for the nurse to assess the level of risk accurately.
D. “We will help get you through this. You'll be fine."
While offering support and reassurance is essential, it doesn't directly address the immediate concern of potential suicidal thoughts. The nurse should assess the client's safety first before providing reassurance.
Correct Answer is C
Explanation
A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.
B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.
C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.
D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.
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