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. Stimulants. Stimulant intoxication typically causes increased energy, agitation, tachycardia, and paranoia, but it does not usually induce hallucinations to the extent described. While severe stimulant use (e.g., methamphetamine or cocaine) can cause paranoia, the significant perceptual disturbances and visual hallucinations suggest a different category of drugs.
B. Opioids. Opioid intoxication generally leads to central nervous system depression, respiratory depression, pinpoint pupils, and sedation rather than paranoia, hallucinations, and erratic behavior. The described symptoms do not align with opioid use.
C. Hallucinogens. Hallucinogen use, such as LSD or PCP, can cause altered perception, paranoia, visual hallucinations, and erratic behavior. The client’s symptoms—paranoia, visual disturbances, mumbling, and gesturing—are characteristic of hallucinogen intoxication, making this the most likely cause.
D. Anabolic steroids. Anabolic steroid use can lead to mood swings, aggression, and psychotic symptoms in some cases, but it does not typically cause acute hallucinations, paranoia, or perceptual disturbances. The symptoms described do not fit anabolic steroid use.

A. "The procedure will take about 2 hours." B. "Most people only require one treatment to eliminate their depression." C. "You may experience a mild headache following the procedure." D. "You will be asleep during the procedure."

Correct Answer is C

Explanation

A. "The procedure will take about 2 hours.": A typical transcranial magnetic stimulation (TMS) session lasts about 30 to 40 minutes. The treatment is conducted on an outpatient basis, allowing clients to resume daily activities immediately afterward.
B. "Most people only require one treatment to eliminate their depression.": TMS is typically administered in multiple sessions over several weeks. A full course usually consists of daily treatments for four to six weeks to achieve significant symptom improvement.
C. "You may experience a mild headache following the procedure.": Mild headaches and scalp discomfort are common side effects of TMS due to repeated magnetic pulses stimulating the brain. These effects are generally temporary and can be managed with over-the-counter analgesics.
D. "You will be asleep during the procedure.": TMS does not require sedation or anesthesia. Clients remain awake and alert during the procedure, as the treatment is noninvasive and does not cause significant discomfort requiring sedation.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is reinforcing teaching to a client who is to undergo transcranial magnetic stimulation (TMS) for depression. Which of the following information should the nurse provide?

Correct Answer is C

Explanation

A nurse is assisting in teaching a client who has been newly diagnosed with schizophrenia. Which of the following information should the nurse include?

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A nurse is caring for a client who has been newly diagnosed with schizophrenia. Which of the following findings is true regarding this disorder?

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A nurse at a primary care clinic is collecting data on a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

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