A nurse is caring for a client who states, "I have been having trouble sleeping for the last several months." Which of the following responses should the nurse make?

Choice A: Client appears to be well-groomed.
Reason: Being well-groomed can indicate that the client is taking care of their personal hygiene and appearance, which is often a sign of improved mental health and self-esteem. This is particularly relevant for clients with anxiety or depression, as neglecting personal care can be a symptom of these conditions.
Choice B: Client’s current weight is 54 kg (119 lb).
Reason: The client’s weight has remained stable since admission (54.4 kg to 54 kg). While this indicates no further weight loss, it does not necessarily indicate an improvement in anxiety symptoms. Weight stability alone is not a direct indicator of mental health improvement.
Choice C: Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Reason: An increase in sleep duration from 3-4 hours to 5-6 hours per night suggests an improvement in the client’s sleep pattern, which is a positive sign in managing anxiety. Occasional nightmares are still present, but the overall increase in sleep is beneficial.
Choice D: Verbalizes decreased appetite and gastrointestinal discomfort.
Reason: Continued decreased appetite and gastrointestinal discomfort indicate ongoing anxiety symptoms. These are not signs of improvement and suggest that the client is still experiencing significant anxiety.
Choice E: Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Reason: This statement reflects ongoing social anxiety and fear of judgment, indicating that the client is still struggling with anxiety symptoms. This is not an indicator of improvement.
Choice F: Verbalizes that bullying experienced during high school has led to anxiety.
Reason: Acknowledging the source of anxiety (bullying) is important for therapy, but it does not directly indicate an improvement in the client’s current anxiety symptoms.
Choice G: Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Reason: Active participation in therapeutic techniques like thought-stopping and cognitive restructuring indicates that the client is engaging in strategies to manage and reduce anxiety. This is a positive sign of improvement.
Choice H: Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
Reason: Consistent medication adherence is crucial for managing anxiety symptoms. The client’s regular intake of escitalopram suggests they are following their treatment plan, which is a positive indicator of improvement.

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.