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. Neurotransmitters are chemical components that allow neurons to store energy for future use. Neurotransmitters do not store energy; they facilitate communication between neurons by transmitting signals across synapses. Their primary function is to modulate brain activity, not energy storage.
B. Neurotransmitters are activated by the enzyme transferase. Neurotransmitters are not activated by transferase. They are synthesized, stored in vesicles, and released into the synaptic cleft in response to an action potential, where they bind to receptors to elicit a response.
C. Neurotransmitters function by inhibiting the production of glucose. Neurotransmitters do not inhibit glucose production. They play a role in neuronal signaling, affecting mood, cognition, and physiological processes, but do not directly regulate glucose metabolism.
D. Neurotransmitters are found throughout the body. Neurotransmitters exist in both the central and peripheral nervous systems, regulating various functions such as mood, movement, and autonomic responses. They are essential for communication between neurons in the brain and throughout the body.
Correct Answer is B
Explanation
A. "Do you think of yourself as more of an introvert? That makes a difference with how you socialize." Social withdrawal in schizophrenia is not related to personality traits like introversion. It is often an early symptom of the disorder, preceding more pronounced psychotic features. Focusing on introversion may mislead the client and overlook the underlying pathology.
B. "Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning." Social withdrawal is a common early sign of schizophrenia, occurring during the prodromal phase. Individuals may withdraw due to subtle cognitive changes, emotional blunting, or emerging paranoid thoughts. Recognizing these early symptoms can aid in early intervention and treatment.
C. "Were you avoiding your friend so that you could hear the voices more clearly?" This statement assumes the client was already experiencing auditory hallucinations, which is not always the case. Social isolation often predates the onset of hallucinations and delusions, making this explanation inaccurate. It may also come across as dismissive rather than informative.
D. "That is very interesting, We are not sure why people start to isolate themselves." While the exact cause of social withdrawal in schizophrenia is not fully understood, research indicates it is an early warning sign. Providing vague or uncertain information may leave the client feeling confused rather than supported in understanding their condition.
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