A nurse is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Body System Findings

Neurologic:	Fatigue after being awake a few hours, feels “restless”. Difficulty concentrating on work and other activities. Difficulty falling asleep and wakes up “after a few hours". Worried about work and family needs.
Musculoskeletal:	Reports muscles feel tight and achy. Ambulates without assistance. Moves all four extremities independently.
Gastrointestinal:	Bowel sounds distant, present x four quadrants. Abdomen soft and nondistended, bladder slightly palpable.
Cardiovascular:	Apical 92/min and regular; peripheral pulses present bilaterally. Absence of lower extremity edema.
Respiratory:	Breath sounds present bilaterally. Occasional dry cough.

Choice A reason:
The statement "Assist the client to use new coping strategies" is important but not the first step. Before introducing new coping strategies, it is essential to build a foundation of trust and rapport. This can only be achieved by first establishing confidentiality guidelines.

Choice B reason:
The statement "Help the client to make behavioral changes" is also crucial but not the initial step. Behavioral changes require a trusting relationship and a safe environment, which are established through clear confidentiality guidelines.

Choice C reason:
The statement "Share information with the client about her disorder" is necessary for education and empowerment but should come after establishing trust. The client needs to feel secure that their information will be kept confidential before they can fully engage in learning about their condition.

Choice D reason:
The statement "Establish confidentiality guidelines with the client" is the correct response. Establishing confidentiality is the first step in building a therapeutic nurse-client relationship. It ensures that the client feels safe and secure in sharing personal information, which is essential for effective treatment and care.

Choice A Reason:
Countertransference occurs when a healthcare provider projects their own personal feelings or experiences onto a client. In this case, the staff nurse is comparing the client to their brother, which indicates that the nurse's personal experiences are influencing their perception of the client. This can affect the nurse's objectivity and the quality of care provided. Recognizing and managing countertransference is crucial to maintaining professional boundaries and providing unbiased care.

Choice B Reason:
Stating that the client needs to accept responsibility for their substance use is a factual statement and does not indicate countertransference. It reflects an understanding of the importance of personal accountability in the recovery process. While the tone and approach of this statement should be empathetic and supportive, it does not suggest that the nurse's personal feelings are influencing their professional judgment.

Choice C Reason:
Noting that the client generally shares their feelings during group therapy sessions is an observational statement based on the client's behavior. It does not indicate countertransference, as it is a factual observation rather than a projection of the nurse's personal experiences or feelings. This type of statement is part of objective documentation and assessment in the therapeutic process.

Choice D Reason:
Refusing a client's inappropriate request, such as asking a nurse on a date, is a professional and appropriate response. It does not indicate countertransference but rather adherence to professional boundaries. The nurse's refusal is based on maintaining a therapeutic and professional relationship, which is essential in the care of clients with substance use disorders.