The nurse maintains a therapeutic relationship with several clients on the behavioral health unit. Which characteristics will be most important for the nurse to foster to maintain these relationships? Select all that apply.

Sharing personal feelings openly with the client

Establishing boundaries for both the nurse and client

Offering sound advice to the client

Avoiding concern with whether the client likes the nurse

Maintaining a client focus at all times

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Sharing personal feelings openly with the client can blur the professional boundaries necessary for a therapeutic relationship and is not typically encouraged.

Choice B reason: Establishing boundaries is crucial in maintaining a professional and therapeutic relationship, ensuring that both the nurse and client understand the limits and expectations of their interactions.

Choice C reason: While offering advice can be part of the therapeutic process, it is more important for the nurse to guide clients in finding their own solutions rather than providing direct advice.

Choice D reason: A therapeutic relationship should be professional and not based on personal feelings. The nurse's concern should be on the client's well-being rather than being liked.

Choice E reason: Maintaining a client focus at all times ensures that the care provided is centered on the client's needs, which is essential in a therapeutic relationship.

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Correct Answer is B

Explanation

Choice A reason: Gastric lavage is typically not the first-line treatment for lithium toxicity due to the risk of aspiration and potential complications. It is usually reserved for cases where the ingestion was recent and massive.

Choice B reason: When a client presents with an extremely elevated lithium level, it is crucial to hold further doses to prevent exacerbation of toxicity. The nurse should monitor for early signs of toxicity, which include gastrointestinal symptoms like nausea, vomiting, diarrhea, and neurological symptoms such as tremors, confusion, and ataxia. The normal therapeutic range for lithium is 0.6 to 1.2 mmol/L, and levels above 1.5 mmol/L are considered toxic.

Choice C reason: While it is important to review the medication record, the immediate concern with an extremely elevated lithium level is addressing the toxicity. Checking the medication record can be part of the assessment process but is not the priority action.

Choice D reason: Administering the morning dose of lithium could worsen the client's condition by increasing the lithium level further, which is already extremely elevated. This could lead to severe toxicity or even fatal consequences.

A. Employ ongoing communication with team members. B. Solve the problems of the client. C. Identify that behavior changes in the clients can occur quickly. D. Consider the client to be a personal friend. E. Discuss feelings of anger or frustration with colleagues.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Ongoing communication with team members is essential in managing care for clients with personality disorders, as it ensures consistency and support among caregivers.

Choice B reason: Solving clients' problems is a goal, but it is not a technique to manage the nurse's frustration.

Choice C reason: Recognizing that behavior changes can occur quickly allows the nurse to adjust care plans promptly and may reduce frustration.

Choice D reason: It is not advisable to consider clients as personal friends, as this can blur professional boundaries and potentially lead to frustration.

Choice E reason: Discussing feelings of anger or frustration with colleagues can provide a support system for the nurse, helping to manage stress and prevent burnout.

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The nurse maintains a therapeutic relationship with several clients on the behavioral health unit. Which characteristics will be most important for the nurse to foster to maintain these relationships? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an extremely elevated lithium level. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is working with clients diagnosed with personality disorders. Which techniques would be most important for the nurse to use to effectively deal with the frustration in providing care to this group of clients? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A nurse is providing care to a client with a situational phobia. Which techniques would the nurse most likely include as an intervention in the client's plan of care? (Select all that apply.)

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? Select all that apply.

A nurse is educating the family of an adolescent client with anorexia nervosa about the issues surrounding this eating disorder. Which statement made by the parent indicates that the education is effective?

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

The nurse is talking with a client diagnosed with histrionic personality disorder. Which statement made by the client does the nurse identify as correlating with this diagnosis?

A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?

The nurse is creating a plan of care for a client with somatic symptom disorder. Which long-term treatment outcomes for this client will be most achievable and measurable? (Select all that apply.)

The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client asks the nurse why all of these questions are being asked. Which techniques will the nurse most likely avoid using to foster more therapeutic responses? Select all that apply.