A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?
Wait for the client to initiate interactions with the nurse.
Set aside short, frequent times each day to spend with the client.
Disclose some personal information to the client.
Tell the client he reminds the nurse of her father.
The Correct Answer is B
Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.
The other options are not appropriate actions:
A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.
C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.
D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Respecting and honoring the autonomy of the clients is important in a mental health setting. Allowing clients to determine the boundaries of the nurse-client relationship empowers them to have control over their own treatment and fosters a sense of autonomy. It encourages clients to express their needs, preferences, and comfort levels in the therapeutic relationship, which can contribute to a more collaborative and effective treatment process.
The other options mentioned are not appropriate actions for the nurse to take:
A. Orienting clients to their responsibilities on the unit is an important task, but it is not specific to the context of a community meeting. It is more relevant during individual client orientations or at the beginning of their admission.
B. Focusing on client weaknesses to increase adaptation is not a therapeutic approach. It is important to focus on clients' strengths and support their growth and development rather than emphasizing weaknesses.
C. Planning to discuss any topic presented by clients can be unfeasible or not relevant in a community meeting. It is essential to have structure and purpose in group discussions to facilitate meaningful interactions.
Correct Answer is C
Explanation
The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:
A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.
B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.
D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.
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