A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

"The client generally shares his feelings during group therapy sessions."

"The client is just like my brother who finally overcame his habit."

"The client asked me to go on a date with him, but I refused."

"The client needs to accept responsibility for his substance use."

Answer and Explanation

The Correct Answer is B

Choice A reason: This statement reflects a neutral observation of the client's behavior in therapy and does not indicate countertransference. Sharing feelings during group therapy sessions is a common and expected part of the therapeutic process, and the staff nurse's comment does not reveal any personal emotional response or projection onto the client.

Choice B reason: This statement is a clear example of countertransference. The staff nurse is identifying the client with a personal family member, which can cloud professional judgment. Such an emotional entanglement may lead to biased care, as the nurse may treat the client based on personal experiences with their brother rather than the client's individual needs and circumstances.

Choice C reason: Declining a client's inappropriate request for a date is a professional boundary that must be maintained. This statement does not reflect countertransference but rather appropriate professional conduct. It is important for the charge nurse to recognize that maintaining boundaries is crucial in a therapeutic setting, especially in cases of substance use disorder where clients may exhibit boundary-testing behaviors.

Choice D reason: This statement could be seen as a professional opinion regarding the client's need for accountability in their recovery process. It does not necessarily indicate countertransference unless the staff nurse's insistence on responsibility is driven by personal feelings or unresolved issues related to substance use.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Ringing in the ears is not a common side effect of lorazepam. This medication is more likely to cause drowsiness or dizziness, which could increase the risk of falls.

Choice B reason: Restraints should only be used as a last resort when all other options have been exhausted and the client is a danger to themselves or others. Lorazepam is used to reduce anxiety, not to sedate to the point where restraints would be necessary.

Choice C reason: Initiating fall precautions is a prudent nursing action after administering lorazepam, especially if given intramuscularly, as the client may experience drowsiness or dizziness, increasing the risk of falls.

Choice D reason: Repeating the dose in 15 minutes is not recommended. The effects of lorazepam should be monitored, and additional doses should be administered based on the client's response and as prescribed by the healthcare provider.

A. Blood glucose 256 mg/dL (74 to 106 mg/dL) B. WBC count 6,000/mm³ (5,000 to 10,000/mm³) C. Platelets 250,000/mm³ (150,000 to 400,000/mm³) D. Sodium 140 mEq/L (136 to 145 mEq/L)

Correct Answer is A

Explanation

Choice A reason: A blood glucose level of 256 mg/dL is significantly higher than the normal range and could indicate hyperglycemia, which is a serious side effect of risperidone. The provider should be notified immediately to manage this potential complication.

Choice B reason: A WBC count of 6,000/mm³ is within the normal range and does not typically warrant concern or the need to notify the provider.

Choice C reason: A platelet count of 250,000/mm³ is also within the normal range and is not indicative of an adverse reaction to risperidone.

Choice D reason: A sodium level of 140 mEq/L falls within the normal range and is not a cause for alarm in the context of risperidone therapy.

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A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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