A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

I may consider dating you once you have fully recovered.

It’s against hospital policy for me to date clients.

This is a professional relationship, and we need to be clear on that.

I’m sorry, but I’m married and not interested in dating.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B Reason:

While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C Reason:

This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D Reason:

Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.

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Correct Answer is A

Explanation

The correct answer is a.

Choice A Reason:

The statement “Ask the client, ‘What are the voices saying to you?’” is correct. Engaging the client in a conversation about their hallucinations can help the nurse understand the content and nature of the hallucinations, which is crucial for assessing the client’s risk of harm to themselves or others. This approach also validates the client’s experience and can help build trust and rapport. It is important to approach the client with empathy and without judgment, as this can help in managing the symptoms more effectively.

Choice B Reason:

The statement “Give the client a PRN dose of benztropine” is incorrect. Benztropine is an anticholinergic medication used to treat extrapyramidal symptoms caused by antipsychotic medications. It is not used to manage auditory hallucinations directly. Administering benztropine without a clear indication could lead to unnecessary side effects and does not address the immediate issue of the hallucinations.

Choice C Reason:

The statement “Call and report the behavior to the physician” is incorrect. While it is important to keep the physician informed about significant changes in the client’s condition, the immediate intervention should focus on addressing the client’s current experience. Reporting the behavior without first attempting to understand and manage the hallucinations may delay appropriate care and support for the client.

Choice D Reason:

The statement “Tell the client, ‘Well, I see you’re distracted right now. We’ll talk more later.’” is incorrect. This response dismisses the client’s current experience and may make them feel misunderstood or ignored. It is important to address the client’s immediate needs and provide support rather than postponing the conversation. Acknowledging the client’s experience and offering to discuss it can help in managing the symptoms and providing appropriate care.

Correct Answer is ["0.63"]

Explanation

To calculate the correct dose:

Identify the prescribed dose: 5 mg
Identify the concentration of the available morphine: 8 mg/mL
Calculate the volume to be administered:
- Volume (mL) = Prescribed dose (mg) ÷ Concentration (mg/mL)
- Volume (mL) = 5 mg ÷ 8 mg/mL
- Volume (mL) = 0.625 mL

The nurse will give 0.63 mL (rounded to the nearest hundredth) for the correct dose.

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A young client asks the nurse for their telephone number, with the intent of calling to schedule a date. Which of the following responses would be most appropriate?

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Naxlex Comprehensive Predictor Exams

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

Correct Answer is A

Explanation

Correct Answer is ["0.63"]

Explanation

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