Which of the following should be the appropriate action by a nurse attempting to develop a therapeutic relationship with a client?
Engage in affectionate interactions with the client.
Promote the use of transference by the client.
Instruct the client on how they should behave.
Set limits for the relationship.
The Correct Answer is D
Choice A reason:
Engaging in affectionate interactions with the client is not appropriate in a therapeutic relationship. Affectionate interactions can blur the professional boundaries necessary for a therapeutic relationship and may lead to dependency or other issues that could compromise the care provided.
Choice B reason:
Promoting the use of transference by the client is not an appropriate action. Transference is a phenomenon where clients project feelings about figures from their past onto a healthcare professional. While recognizing transference is important, promoting it is not advised as it can interfere with the objectivity of care.
Choice C reason:
Instructing the client on how they should behave is not typically conducive to developing a therapeutic relationship. It may be perceived as paternalistic or authoritarian, which can undermine trust and hinder the establishment of a collaborative relationship.
Choice D reason:
Setting limits for the relationship is the correct action. Establishing clear boundaries helps maintain a professional and therapeutic relationship. It ensures that both the nurse and the client understand the expectations and limits of their interactions, which is essential for effective treatment and the client's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Primary prevention in community mental health is focused on reducing the incidence of mental disorders within the population. This proactive approach involves strategies and interventions designed to prevent the onset of mental health issues before they manifest. It includes enhancing individual resilience, fostering a supportive environment, and promoting mental well-being to lower the incidence and impact of mental health problems.
Choice B reason:
Services aimed at reducing the residual defects associated with severe and persistent mental illness fall under tertiary prevention. Tertiary prevention focuses on reducing the negative impact of an already established disease by restoring function and reducing disease-related complications.
Choice C reason:
Early identification of problems and prompt initiation of effective treatment are aspects of secondary prevention. Secondary prevention aims to reduce the impact of a disease that has already occurred, through early detection and appropriate treatment to halt or slow its progression.
Choice D reason:
Interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness can be considered part of both secondary and tertiary prevention. These interventions work to alleviate the effects of an existing condition and prevent it from becoming more severe or prolonged.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
The correct answer is: B and D.
Choice A: Heart Failure
Heart failure is a potential complication of anorexia nervosa due to malnutrition and electrolyte imbalances, which can affect cardiac function. However, the client’s current diagnostic results do not directly indicate heart failure. The blood pressure and heart rate are low but not critically so, and there are no specific cardiac markers or symptoms mentioned that would suggest imminent heart failure.
Choice B: Renal Failure
Renal failure is a significant risk for this client. The elevated BUN (31 mg/dL) and creatinine (3.0 mg/dL) levels indicate impaired kidney function. These values are well above the normal ranges (BUN: 10-20 mg/dL, creatinine: 0.5-1.0 mg/dL), suggesting that the kidneys are not effectively filtering waste products from the blood. This is consistent with renal failure, which can be exacerbated by dehydration and electrolyte imbalances common in anorexia nervosa.
Choice C: Hypomagnesemia
Hypomagnesemia refers to low magnesium levels in the blood. The client’s magnesium level is 2.2 mEq/L, which is within the normal range (1.3-2.1 mEq/L). Therefore, hypomagnesemia is not a current risk for this client based on the provided lab results.
Choice D: Hypothyroidism
Hypothyroidism is a condition where the thyroid gland does not produce enough thyroid hormones. The client’s free thyroxine (T4) level is 0.4 ng/dL, which is below the normal range (0.8-2.8 ng/dL). This indicates hypothyroidism, which can cause symptoms such as fatigue, weight gain, and depression78. Given the client’s history of anorexia nervosa and the current lab results, hypothyroidism is a significant risk.
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