A nurse manager and a newly licensed nurse are engaged in an interview with a client. The newly licensed nurse tells the client, "You look like my sister. I love my sister and would do anything for her." Which of the following actions should the nurse manager take?
Inform the newly licensed nurse that they are successfully building trust and rapport.
Ask the newly licensed nurse if they are comfortable providing care to the client.
Record that the newly licensed nurse is able to maintain professional nurse-client boundaries.
Assign the newly licensed nurse to a different client.
The Correct Answer is D
A. Inform the newly licensed nurse that they are successfully building trust and rapport. While therapeutic communication is essential, personalizing the interaction in this way crosses professional boundaries. Comparing a client to a family member can create unrealistic expectations and blur the nurse-client relationship. Maintaining professional distance ensures objective and ethical care.
B. Ask the newly licensed nurse if they are comfortable providing care to the client. While assessing a nurse’s comfort level is important, it does not address the boundary violation. The concern is not about the nurse's comfort but about maintaining professionalism in client interactions. Direct intervention is needed to correct the inappropriate statement and reinforce professional conduct.
C. Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. The statement made by the newly licensed nurse demonstrates a boundary issue rather than professionalism. Nurses should establish rapport without over-identification with clients. Documenting that the nurse maintained boundaries would be inaccurate and fail to address the issue.
D. Assign the newly licensed nurse to a different client. The statement suggests an emotional attachment that may interfere with objective care. Reassigning the nurse prevents further boundary issues and allows for education on maintaining professionalism. Ensuring appropriate nurse-client relationships promotes ethical practice and patient-centered care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. To keep the client's environment calm and with minimal daily stimuli: While a calm environment can help manage acute psychotic symptoms, it is a short-term intervention rather than a long-term goal. Long-term management focuses on adherence to treatment and relapse prevention.
B. To be reoriented to their current environment as needed: Reorientation is beneficial for clients experiencing disorientation due to acute psychosis, but it is a short-term intervention. A long-term goal should focus on maintaining stability and preventing future relapse.
C. To ensure the client participates in a walk with staff on a daily basis: Regular physical activity can improve mental health, but it does not directly address medication adherence or long-term relapse prevention. The goal should focus on strategies to maintain treatment compliance.
D. To develop and acknowledge understanding of a relapse plan prior to discharge: A relapse plan helps the client recognize early warning signs, understand medication importance, and seek support when needed, which is essential for long-term symptom management and prevention of future hospitalizations.
Correct Answer is D
Explanation
A. Paranoid personality disorder. Paranoid personality disorder is characterized by distrust and suspicion of others without delusions or hallucinations. Individuals may misinterpret benign interactions as threatening but do not typically display magical thinking or bizarre beliefs.
B. Antisocial personality disorder. Antisocial personality disorder involves a disregard for social norms, manipulation, and lack of empathy. Individuals with this disorder do not usually exhibit delusions or claims of supernatural abilities.
C. Avoidant personality disorder. Avoidant personality disorder is marked by social inhibition, feelings of inadequacy, and hypersensitivity to criticism. These individuals avoid social situations but do not exhibit magical thinking or unusual beliefs.
D. Schizotypal personality disorder. Schizotypal personality disorder involves eccentric behavior, unusual thinking, and cognitive distortions such as magical thinking and paranoia. The belief that one can read minds is a characteristic feature of this disorder.
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