A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?
Confirming boundaries by setting limits on behavior.
Providing reality orientation.
Providing client education in a direct manner.
Ensuring physical need fulfillment.
The Correct Answer is A
Choice A Reason:
Confirming boundaries by setting limits on behavior.
This response is correct because it directly addresses the need to set clear boundaries with the client. In a psychiatric setting, it is crucial to establish and maintain professional boundaries to ensure a therapeutic environment. By limiting the client’s approach to the nurse’s station, the nurse is setting a clear boundary that helps manage the client’s behavior and ensures that the nurse can attend to other patients as well. This intervention helps in maintaining structure and predictability, which can be very beneficial for clients with psychiatric conditions.
Choice B Reason:
Providing reality orientation.
Providing reality orientation involves helping clients understand their surroundings and current situation, often used for clients with cognitive impairments or disorientation. While important, this intervention does not specifically address the behavior of frequently approaching the nurse’s station. Reality orientation would be more relevant in cases where the client is confused about time, place, or person.
Choice C Reason:
Providing client education in a direct manner.
Providing client education is essential, but it does not directly relate to setting behavioral limits. Education might involve explaining the reasons behind certain rules or treatments, but it does not address the immediate need to manage the client’s frequent requests. The intervention described in the question is more about behavior management than education.
Choice D Reason:
Ensuring physical need fulfillment.
Ensuring physical need fulfillment involves addressing the client’s basic needs such as food, hydration, and comfort. While this is a fundamental aspect of nursing care, it does not relate to setting behavioral limits or managing the frequency of the client’s requests. The intervention in the question is focused on managing behavior rather than fulfilling physical needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Acupuncture.
Acupuncture is a traditional Chinese medicine practice that involves inserting thin needles into specific points on the body to balance energy flow and promote healing. While it is a form of manual therapy, it is not part of chiropractic medicine. Chiropractors focus on the musculoskeletal system, particularly the spine, and do not typically use acupuncture as a primary treatment modality.
Choice B Reason:
Surgical procedures.
Surgical procedures are not part of chiropractic medicine. Chiropractors are not licensed to perform surgeries. Their practice is centered around non-invasive treatments, primarily involving manual adjustments and manipulations of the spine and other joints. Surgery is outside the scope of chiropractic care and is typically handled by medical doctors or surgeons.
Choice C Reason:
Spinal manipulation.
This is the correct response. Spinal manipulation, also known as chiropractic adjustment, is a core component of chiropractic medicine. Chiropractors use their hands or specialized instruments to apply controlled force to spinal joints, aiming to improve spinal alignment, reduce pain, and enhance physical function. This technique is fundamental to chiropractic care and distinguishes it from other forms of manual therapy.
Choice D Reason:
Prescription medications.
Prescription medications are not part of chiropractic medicine. Chiropractors do not prescribe medications; instead, they focus on manual therapies, exercise, and lifestyle counseling to manage and prevent musculoskeletal issues. The use of medications is typically managed by medical doctors or other healthcare providers.
Correct Answer is ["A","B","E"]
Explanation
Choice A Reason:
It is extremely important to maintain professional boundaries with clients.
Maintaining professional boundaries is crucial in nursing to ensure a therapeutic and trusting relationship between the nurse and the client. Crossing these boundaries can lead to ethical issues and compromise the care provided. In this scenario, the nurse allowed personal relationships to influence professional behavior, which is inappropriate and can undermine the client’s trust and the integrity of the nurse-client relationship.
Choice B Reason:
Countertransference may have been a factor in your actions with this client.
Countertransference occurs when a nurse’s personal feelings and experiences influence their professional interactions with a client. In this case, the nurse’s familiarity with the client as a childhood friend of a sibling may have led to biased actions, such as allowing the use of a personal mobile device and sharing confidential information. Recognizing and managing countertransference is essential to maintain objectivity and provide unbiased care.
Choice C Reason:
It would have been better if you called your sibling instead of texting.
This statement is not relevant to the primary issues at hand. Whether the nurse called or texted their sibling does not change the fact that sharing the client’s hospitalization status was a breach of confidentiality. The focus should be on the inappropriate disclosure of protected health information, not the method of communication.
Choice D Reason:
Policies can be amended for clients who are admitted voluntarily, not involuntarily.
This statement is incorrect. Policies regarding the use of personal mobile devices and confidentiality apply to all clients, regardless of whether they are admitted voluntarily or involuntarily. The nurse’s actions violated these policies, and the distinction between voluntary and involuntary admission does not justify the breach.
Choice E Reason:
You have violated HIPAA regulations by notifying your sibling of the client’s admission.
This is the correct response. The nurse violated HIPAA regulations by disclosing the client’s hospitalization status to their sibling without the client’s consent. HIPAA protects the privacy of individuals’ health information, and unauthorized disclosure is a serious violation that can result in legal and professional consequences.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today