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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. "When attending dialectical behavior therapy." Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder (BPD) manage emotions and reduce self-harming behaviors. While therapy can bring up distressing emotions, it provides structured support and coping strategies. The risk of self-harm is lower when clients are actively engaged in treatment and receiving professional guidance.
B. "When getting married." Major life changes, including marriage, can be stressful for individuals with BPD, but they do not inherently pose the highest risk for self-harm. Support from a partner and structured therapy can help navigate emotional challenges. While instability in relationships can trigger distress, the protective factors of marriage may reduce immediate risk. Self-harm risk is typically higher in periods of transition without support.
C. "When discharged from the hospital." Clients with BPD often struggle with emotional regulation, and discharge represents a significant transition with decreased support. The sudden loss of a structured inpatient setting can increase feelings of abandonment and distress, leading to a heightened risk of self-harm. Ensuring a follow-up care plan and support system is crucial to reducing this risk after hospitalization.
D. "When attending narrative therapy." Narrative therapy helps clients reframe their experiences and build a stronger sense of identity. Although deep emotional topics may be explored, structured therapy provides a safe space for expression. Therapeutic interventions aim to reduce distress and teach coping mechanisms, decreasing the likelihood of self-harm. The highest risk occurs when structured support is suddenly removed.

A. "Do you need any more resources or information?" B. "Do you understand your next step in treatment?" C. "You feel like you have the support needed to be successful." D. "Tell me what kind of coping skills you have."

Correct Answer is C

Explanation

A. "Do you need any more resources or information?" This question focuses on offering additional resources rather than encouraging the client to explore their emotions. While it is useful for providing support, it does not promote self-reflection or invite the client to clarify their feelings. Therapeutic communication should aim to encourage deeper discussion rather than just addressing practical needs.
B. "Do you understand your next step in treatment?" Although this question ensures the client comprehends their treatment plan, it does not foster emotional expression or self-awareness. Understanding the next steps in care is important, but therapeutic communication should focus on exploring the client’s internal experiences rather than just confirming information. Encouraging open-ended reflection is more effective for clarifying emotions.
C. "You feel like you have the support needed to be successful." This statement encourages self-reflection and allows the client to clarify their feelings about their support system. It promotes therapeutic communication by inviting the client to assess their emotional needs and level of confidence. Open-ended statements like this help build trust and provide insight into the client’s concerns and perceptions.
D. "Tell me what kind of coping skills you have." While this question assesses the client's coping strategies, it does not directly facilitate emotional clarification. Asking about coping skills is useful for intervention planning, but it does not specifically address the client’s feelings. A more effective therapeutic approach would involve asking how the client feels about their ability to manage stress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing borderline personality disorder and the risk for self-harm with a newly licensed nurse. Which of the following situations should the nurse identify as the highest risk for self-harm?

Correct Answer is C

Explanation

A nurse is preparing to interview a client and is reviewing therapeutic communication techniques. Which of the following should the nurse include in the interview to invite the client to clarify feelings?

Correct Answer is C

Explanation

A nurse is caring for a client who is diagnosed with schizophrenia. Which of the following manifestations should the nurse identify as a negative symptom?

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A nurse is discussing schizophrenia spectrum disorders with a client. The client states, "My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?" Which of the following responses should the nurse make?

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