During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?

Identify the client's transference of feelings of annoyance.

Resolve the feelings with the client after discharge.

Share similar experiences the nurse has had in the past.

Terminate the session before the feelings escalate.

Answer and Explanation

The Correct Answer is D

Choice A reason: Identifying transference assumes the client’s behavior caused the nurse’s anger, which may not be accurate. Terminating the session prevents untherapeutic escalation, allowing the nurse to regain composure. This choice risks misattributing emotions, making it incorrect for managing the nurse’s immediate anger.

Choice B reason: Resolving feelings after discharge delays addressing the nurse’s current anger, risking unprofessional behavior during the session. Terminating the session maintains therapeutic boundaries, making this incorrect, as it postpones action needed to manage the immediate emotional reaction effectively.

Choice C reason: Sharing personal experiences is untherapeutic and shifts focus from the client, potentially worsening the nurse’s anger. Terminating the session preserves professionalism and boundaries, making this incorrect, as self-disclosure does not address the nurse’s emotional state or maintain a therapeutic environment.

Choice D reason: Terminating the session before anger escalates allows the nurse to regain composure, preserving therapeutic boundaries and preventing unprofessional behavior. This action prioritizes client care and nurse self-awareness, aligning with psychiatric nursing ethics, making it the best choice for managing the nurse’s emotions.

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Correct Answer is A

Explanation

Choice A reason: Offering to sit with the client provides empathetic presence, addressing the isolation of depression without pressuring activity. This fosters connection and support, critical for a reclusive, depressed client, aligning with psychiatric nursing principles for building therapeutic rapport in chronic depression, making it the most helpful comment.

Choice B reason: Inviting the client to the recreation area may feel coercive to a depressed, reclusive client, increasing withdrawal. Offering quiet companionship respects his current state and encourages engagement gently, making this less helpful and incorrect for addressing his immediate emotional needs effectively.

Choice C reason: Acknowledging family absence may validate sadness but risks dismissing the client’s feelings by justifying the situation. Sitting with him offers direct support, fostering connection. This comment is less therapeutic, as it may not address his isolation, making it incorrect for immediate support.

Choice D reason: Asking why he stays in his room may seem confrontational to a depressed client, potentially increasing withdrawal. Offering to sit with him builds trust without demanding explanation, aligning with supportive care for depression. This question is less helpful, making it incorrect for fostering engagement.

A. Cancer screening results, anger, gastritis, daily alcohol intake. B. Efforts to cut down, annoyance with questions, guilt, drinking as an "eye-opener." C. Consumption, liver enzyme, gastrointestinal complaints and bleeding. D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.

Correct Answer is B

Explanation

Choice A reason: Cancer screening, anger, gastritis, and daily intake are not part of the CAGE questionnaire, which focuses on cut down, annoyance, guilt, and eye-opener. These factors are unrelated to the validated screening tool, making this incorrect for exploring alcohol use based on CAGE criteria.

Choice B reason: The CAGE questionnaire screens for alcohol dependence by assessing efforts to cut down, annoyance when questioned, guilt about drinking, and using alcohol as an eye-opener. These directly identify problematic drinking patterns, aligning with addiction screening evidence, making this the correct choice for in-depth exploration.

Choice C reason: Consumption, liver enzymes, and gastrointestinal issues are relevant to alcohol use but not part of the CAGE questionnaire. CAGE focuses on behavioral indicators like guilt and annoyance. This choice includes non-CAGE criteria, making it incorrect for the screening tool’s specific focus.

Choice D reason: Minimizing drinking and missing family events are not CAGE criteria, though guilt is. The full CAGE framework (cut down, annoyance, guilt, eye-opener) better captures alcohol dependence. This choice is incomplete and includes non-CAGE items, making it incorrect for CAGE-based exploration.

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During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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