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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. "Talking about the traumatic experience is recommended."
This statement is generally correct. Many therapeutic approaches for PTSD, such as cognitive-behavioral therapy (CBT) and exposure therapy, involve talking about the traumatic experience in a controlled and supportive environment. However, the timing and method of discussing the trauma should be guided by a mental health professional.

B. "Response prevention is an effective treatment for PTSD."
This statement is incorrect. Response prevention is a therapeutic technique often used in the treatment of anxiety disorders like obsessive-compulsive disorder (OCD). It involves preventing the usual response to a trigger. However, for PTSD, exposure therapy, cognitive restructuring, and EMDR (Eye Movement Desensitization and Reprocessing) are more common therapeutic approaches.

C. "You should try to limit the number of hours that you sleep each day."
This statement is incorrect. Adequate sleep is crucial for overall mental and physical health, and disrupting sleep patterns can worsen symptoms of PTSD. Sleep disturbances are common in PTSD, and part of managing the disorder often involves addressing sleep problems.

D. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD."
This statement is generally correct. Avoiding triggers that bring back memories of the trauma is a common coping strategy. However, while avoidance might provide short-term relief, it's not a long-term solution. Evidence-based therapies often involve confronting and processing these triggers in a safe and controlled way, under the guidance of a therapist.

A. The client states that he will harm himself unless the restraints are removed. B. The client demonstrates that he is oriented to person, place, and time. C. The client is able to follow commands. D. The client refuses to take his medication unless he is released.

Correct Answer is B

Explanation

A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.

B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.

C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.

D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

Correct Answer is B

Explanation

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