A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Defensive coping reaction

The presence of countertransference

The presence of transference

Catastrophic reaction

Answer and Explanation

The Correct Answer is B

Choice A reason: Defensive coping involves mechanisms like denial to manage stress, not personal emotional connections to a patient. The nurse’s sadness reflects personal feelings, not a defense against anxiety. This term does not apply to the nurse’s emotional response to the patient’s condition or perceived helplessness.

Choice B reason: Countertransference occurs when a nurse projects personal feelings, like sadness, onto a patient due to similarities with personal experiences (e.g., grandparents). This emotional response can influence care if not managed, as it stems from the nurse’s unresolved feelings, making it the accurate description of the situation.

Choice C reason: Transference involves the patient projecting feelings onto the nurse, not the nurse’s emotions about the patient. The scenario describes the nurse’s feelings, not the patient’s, making transference inapplicable. The nurse’s sadness reflects personal emotional involvement, not a patient-driven dynamic.

Choice D reason: Catastrophic reaction refers to a patient’s exaggerated emotional response to stress, often in dementia, not the nurse’s feelings. The nurse’s sadness is a personal emotional reaction, not a patient behavior, making this term irrelevant to the described situation of the nurse’s emotional reflection.

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Correct Answer is D

Explanation

Choice A reason: Releasing the client when behavioral control is achieved aligns with autonomy and beneficence, not nonmaleficence. While it benefits the client, it does not directly address harm prevention, which is the core of nonmaleficence. The focus is on restoring freedom, not specifically ensuring no physical harm during restraint use.

Choice B reason: Explaining release requirements promotes understanding and autonomy but does not directly prevent harm, the focus of nonmaleficence. It supports therapeutic communication but does not address the physical safety risks of restraints, such as skin breakdown or circulation issues, making it less relevant to this principle.

Choice C reason: Applying restraints based on assessment, not attitude, ensures objectivity, aligning with justice and fairness. While this prevents inappropriate restraint use, it is less directly tied to nonmaleficence, which focuses on avoiding harm like injury during restraint application, making it a secondary consideration in this context.

Choice D reason: Assuring restraints do not cause injury directly upholds nonmaleficence, the ethical principle of avoiding harm. Regular checks for skin breakdown, circulation impairment, or nerve damage prevent physical harm, ensuring safety during restraint use, making this action the most aligned with nonmaleficence in a restrained client.

A. Say to the interrupting patient, “I am not available to talk with you at the present time” B. End the unproductive session with the current patient and spend time with the patient who has just interrupted C. Invite the interrupting patient to join in the session with the current patient D. Tell the patient who interrupted, “This session will be 5 more minutes; then, I will talk with you”

Correct Answer is D

Explanation

Choice A reason: Bluntly stating unavailability dismisses the interrupting patient’s needs without offering a solution, potentially escalating distress. This approach lacks therapeutic communication, as it fails to acknowledge the patient’s urgency or provide a clear plan, which is critical in maintaining trust in a mental health setting.

Choice B reason: Ending the current session prematurely disrespects the silent patient’s therapeutic process. Silence may reflect processing or discomfort, requiring time to build trust. Abruptly shifting focus undermines the current patient’s care, potentially worsening their mental health and disrupting the therapeutic relationship.

Choice C reason: Inviting the interrupting patient to join violates confidentiality and disrupts the current patient’s safe space. Combining sessions without consent breaches ethical principles, potentially causing discomfort or mistrust, which hinders therapeutic progress for both patients in a mental health context.

Choice D reason: Acknowledging the interruption and scheduling a follow-up in 5 minutes respects both patients’ needs. It maintains the current patient’s therapeutic time while addressing the interrupting patient’s urgency, ensuring fairness and trust. This approach upholds ethical care and supports a therapeutic environment for mental health treatment.

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A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence?

Correct Answer is D

Explanation

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

Correct Answer is D

Explanation

The client feels that the client’s rights have been violated. Placing a client in restraints before using other methods of intervention violates which of the client’s rights?

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Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?

A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?