A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

Set limits for the relationship.

Engage in affectionate interactions with the client.

Promote the use of transference by the client.

Instruct the client on how he should behave.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: Set limits for the relationship.

Choice A rationale:

Setting limits for the therapeutic relationship (Choice A) is an essential nursing action. Boundaries help create a safe and structured environment, ensuring that both the nurse and client maintain appropriate roles. Limits prevent overstepping boundaries that could compromise the therapeutic alliance. Setting limits for the relationship is an essential part of establishing a therapeutic relationship in a mental health setting. This helps to maintain professional boundaries and ensures that the relationship remains focused on the client’s needs and therapeutic goals.

Choice B rationale:

Engaging in affectionate interactions with the client (Choice B) is not appropriate in a therapeutic relationship. Professionalism and maintaining appropriate boundaries are crucial in psychiatric nursing. Affectionate interactions could blur the lines between the therapeutic relationship and personal relationships, potentially harming the client's progress.

Choice C rationale:

Promoting the use of transference by the client (Choice C) is not a suitable approach. Transference occurs when a client projects feelings and emotions onto the nurse based on past experiences. While it can be valuable to explore transference, actively promoting it could lead to confusion and misunderstandings in the therapeutic relationship.

Choice D rationale:

Instructing the client on how they should behave (Choice D) is contrary to the principles of a therapeutic relationship. The therapeutic relationship is client-centered, where the nurse supports the client's self-discovery and growth. Directing the client's behavior undermines their autonomy and inhibits their progress.

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Correct Answer is A

Explanation

Choice A rationale:

Ideas of reference involve the belief that external events, objects, or people have a specific and unusual significance directly related to oneself. In this scenario, the client with schizophrenia believes that the group's laughter is directed at them, indicating an exaggerated sense of personal relevance in the situation.

Choice B rationale:

Erotomania is characterized by the delusional belief that someone, usually of higher social status, is in love with the individual. This choice is not applicable to the situation described, where the client's reaction is centered around perceived mockery rather than romantic interest.

Choice C rationale:

Grandeur involves inflated feelings of importance, power, knowledge, or identity. It does not align with the situation where the client perceives ridicule and responds defensively to the group's laughter.

Choice D rationale:

Flight of ideas is a thought disorder characterized by rapid and unconnected shifts in thoughts, often associated with mania. It is not relevant to the client's reaction to the group's laughter.

A. Approach the client frequently throughout the day for brief interactions. B. Disclose some personal information to the client to demonstrate approachability. C. Adopt a neutral attitude when providing care. D. Wait for the client to initiate interaction.

Correct Answer is C

Explanation

Choice A rationale:

Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.

Choice B rationale:

Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.

Choice C rationale:

Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.

Choice D rationale:

Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.

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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following should be the appropriate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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