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. Diagnosis typically occurs after 40 years of age. Diagnosis typically occurs in late adolescence to early adulthood, not after 40 years of age. While late-onset schizophrenia can occur, it is less common. The disorder usually manifests in the late teens to early 30s, with males often presenting earlier than females.
B. Life expectancy is greater than the general population. Life expectancy is lower than the general population due to factors such as increased risk of suicide, cardiovascular disease, and reduced access to healthcare. The presence of comorbid conditions and lifestyle factors, including smoking and poor diet, further contribute to a shorter lifespan.
C. Co-occurring mental health illnesses are rarely diagnosed. Co-occurring mental health illnesses are frequently diagnosed in individuals with schizophrenia. Conditions such as depression, anxiety disorders, and substance use disorders are common. These comorbidities can complicate treatment and impact overall prognosis.
D. The need for resources increases as the disease progresses into adulthood. The need for resources increases as the disease progresses into adulthood due to worsening functional impairment. Individuals with schizophrenia often require long-term support, including medication management, social services, and rehabilitation programs to maintain stability and quality of life.
Correct Answer is D
Explanation
A. "Lately, I feel like I am more alert than usual and can focus better.": Depression is commonly associated with difficulties in concentration, memory impairment, and slowed cognitive function rather than increased alertness or improved focus. Clients with depression often report feeling mentally sluggish or experiencing brain fog.
B. "I can't sit still. I feel like I need to be doing things around the house.": While some individuals with depression experience psychomotor agitation, it is more common for depression to present with fatigue, low energy, and decreased motivation. Restlessness may also be seen in anxiety disorders, but it is not a primary symptom of depression.
C. "When I went to my provider, they told me I have high blood pressure.": Hypertension is a medical condition that may have various causes, but it is not a direct manifestation of depression. However, chronic stress and depression can contribute to cardiovascular issues over time, though depression itself is primarily characterized by emotional and cognitive symptoms.
D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.": Insomnia and difficulty falling or staying asleep are hallmark symptoms of depression. Clients often experience ruminative thoughts, early-morning awakenings, or non-restorative sleep, which can contribute to worsened mood, fatigue, and impaired daily functioning.
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