A nurse is assessing a client diagnosed with schizophrenia, which has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?

Choice A rationale:

Existing conditions can indeed be a predisposing factor for stress. Chronic medical conditions, financial difficulties, or interpersonal conflicts can contribute to increased stress levels. These existing conditions create a foundation for stress to manifest.

Choice B rationale:

Heredity can also play a role in predisposing individuals to stress. Genetic factors can influence how a person responds to stressors and copes with challenging situations. A family history of anxiety disorders, for example, might increase an individual's susceptibility to stress.

Choice C rationale:

Learned responses are another predisposing factor for stress. If an individual has experienced traumatic events or has learned maladaptive coping mechanisms in response to stressors, they may be more prone to feeling stressed when faced with similar situations in the future.

Choice D rationale:

History of hypotension is the correct answer. Hypotension refers to abnormally low blood pressure. While it can have its own effects on the body, it is not typically considered a predisposing factor for stress. Stress is more closely associated with psychological and environmental factors rather than a person's blood pressure history.

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.