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 C

Explanation

Choice A rationale:

The Brief Patient Health naire (Brief PHQ) is primarily used for assessing the presence and severity of depressive symptoms and not specifically for cognitive disorders. It consists of nine items that assess the frequency of specific symptoms over the past two weeks.

Choice B rationale:

The Scale for Assessment of Negative Symptoms (SANS) is a tool used to assess negative symptoms in schizophrenia and other related psychotic disorders. It includes items related to affective blunting, alogia, anhedonia, and avolition, which are not directly relevant to the assessment of cognitive disorders.

Choice C rationale:

The Mental Status Examination (MSE) is a comprehensive assessment of cognitive function, including orientation, memory, attention, language, and executive function. It provides valuable information about the client's cognitive abilities and can aid in diagnosing cognitive disorders such as dementia or delirium.

Choice D rationale:

The Abnormal Involuntary Movements Scale (AIMS) is used to assess the presence and severity of tardive dyskinesia, a movement disorder commonly associated with the use of antipsychotic medications. It is not relevant to the assessment of cognitive disorders.

A. Decreases or eliminates a behavior by introducing a more adaptive behavior that is incompatible with the unacceptable behavior. B. Is an aversion therapy that produces unpleasant consequences for undesirable behavior. C. An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. D. Relies on individual's imagination rather than medication for unpleasant symptoms.

Correct Answer is B

Explanation

The correct answer is choice B: Is an aversion therapy that produces unpleasant consequences for undesirable behavior.

Choice A rationale:

Decreases or eliminates a behavior by introducing a more adaptive behavior that is incompatible with the unacceptable behavior. Choice A refers to the technique of "differential reinforcement," where an undesirable behavior is replaced by a more appropriate behavior. This technique involves reinforcing positive behaviors while ignoring or providing minimal attention to negative behaviors. It is not the same as covert sensitization.

Choice B rationale:

Is an aversion therapy that produces unpleasant consequences for undesirable behavior. Covert sensitization is a form of aversion therapy used to eliminate unwanted behaviors by associating them with unpleasant imagery or thoughts. It's based on the principle that if a person can associate a negative response with a certain behavior, they will be less likely to engage in that behavior. This technique is used for behaviors like addiction or certain compulsive behaviors.

Choice C rationale:

An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. Choice C refers to "time-out," a technique used to decrease undesirable behaviors by removing the individual from the environment where the behavior is occurring. This is often used with children and involves giving them a brief break from a situation to help them calm down. It's not the same as covert sensitization.

Choice D rationale:

Relies on an individual's imagination rather than medication for unpleasant symptoms. Choice D is not directly related to covert sensitization. Covert sensitization involves creating a negative association with a behavior using mental imagery. It's not about relying on imagination instead of medication.

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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?

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