A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?
Implementation
Evaluation
Assessment
Planning
The Correct Answer is C
Choice A reason:
Implementation involves carrying out the interventions outlined in the care plan. This phase focuses on executing the planned actions to achieve the desired outcomes and does not include gathering initial information about the client’s history.
Choice B reason:
Evaluation involves assessing the effectiveness of the interventions and determining whether the goals of the care plan have been met. This phase occurs after the initial assessment and implementation of interventions.
Choice C reason:
Assessment is the first phase of the nursing process, where the nurse gathers comprehensive information about the client’s health status, including their family history of schizophrenia. This information is crucial for developing an accurate diagnosis and care plan.
Choice D reason:
Planning involves setting goals and determining the appropriate interventions based on the assessment data. While planning is essential, it follows the assessment phase and relies on the information gathered during the assessment.
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Correct Answer is C
Explanation
Choice A reason:
Projection involves attributing one’s own unacceptable thoughts or feelings to others. This is not the correct answer because the man’s behavior of punching walls and yelling at his significant other is an outward expression of his own frustration, rather than projecting his feelings onto someone else. Projection would involve accusing others of having the feelings or thoughts that he himself is experiencing.
Choice B reason:
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. This is not the correct answer because the man’s actions indicate that he is reacting to his frustration rather than denying its existence. Denial would involve ignoring or refusing to acknowledge the feelings or situation that is causing distress.
Choice C reason:
Displacement is the redirection of emotions or impulses from a threatening target to a safer one. This is the correct answer because the man redirects his anger from his supervisor, who is the source of his frustration, to a less threatening target, which is his significant other and the walls at home. Displacement allows the individual to express their emotions in a way that feels safer or more acceptable.
Choice D reason:
Passive-aggression involves expressing negative feelings indirectly rather than openly addressing them. This is not the correct answer because the man’s behavior is direct and aggressive, rather than passive. Passive-aggressive actions might include sulking, procrastination, or subtle resistance, none of which are evident in the described scenario.
Correct Answer is A
Explanation
Choice A reason:
Countertransference occurs when a healthcare provider projects their own feelings and experiences onto the client. In this case, the nurse is responding to the client as if they were their grandparent, which indicates that the nurse’s personal feelings are influencing their professional relationship.
Choice B reason:
Empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing, it does not involve projecting personal relationships onto the client.
Choice C reason:
Transference occurs when a client projects feelings about important figures in their life onto the healthcare provider. This is the opposite of countertransference, where the provider projects their feelings onto the client.
Choice D reason:
Modeling involves demonstrating behaviors for others to imitate. It does not describe the emotional reaction of projecting personal feelings onto a client.
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