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","B","D","E"]

Explanation

The correct answer is Choice A, Choice B, Choice D, Choice E.

Choice A rationale: Offering specific privileges for sustained weight gain acts as positive reinforcement, motivating the client to adhere to the treatment plan. It supports behavior change and helps in gradually restoring a healthy weight, vital in anorexia nervosa management.

Choice B rationale: Monitoring the client's weight daily allows for accurate tracking of progress and ensures timely intervention if weight loss continues. It helps the healthcare team make necessary adjustments to the treatment plan to meet nutritional and therapeutic goals.

Choice C rationale: Allowing the client to choose their meals can lead to poor nutritional choices due to their distorted perception of body image and fear of gaining weight. Structured meal plans are essential to ensure balanced nutrition and recovery in anorexia nervosa.

Choice D rationale: Providing the client with small meals frequently helps in preventing overwhelming feelings during meals and reduces the risk of refeeding syndrome. This approach promotes consistent nutritional intake and supports gradual weight gain.

Choice E rationale: Staying with the client during meals and for 1 hour afterward prevents purging behaviors and provides emotional support. It also ensures the client consumes the prescribed food, facilitating adherence to the nutritional plan and promoting recovery.

A. Death of client's father two months ago. B. Adheres strictly to routines. C. Suspended from school several times in the past year. D. Experiences frequent facial tics.

Correct Answer is C

Explanation

The correct answer is choice C. Suspended from school several times in the past year.

Choice A rationale:

The client's father's recent death (Choice A) is not a typical expected assessment finding of conduct disorder. While emotional disturbances can be associated with conduct disorder, the primary characteristics involve behavioral issues rather than reactions to significant life events.

Choice B rationale:

Adhering strictly to routines (Choice B) is not a common expected assessment finding of conduct disorder. Conduct disorder is characterized by patterns of defiant and disruptive behaviors, not necessarily a rigid adherence to routines.

Choice C rationale:

Suspended from school several times in the past year (Choice C) aligns with the expected assessment findings of conduct disorder. Conduct disorder often involves aggressive behavior towards others, violation of rules, and disregard for the rights of others, which can lead to disciplinary actions such as school suspensions.

Choice D rationale:

Experiencing frequent facial tics (Choice D) is not a typical expected assessment finding of conduct disorder. Facial tics are associated with conditions like Tourette's syndrome or other tic disorders, not conduct disorder.

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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

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Explanation

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Explanation

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