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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A: "You may experience dizziness upon standing while taking this medication."
Choice A rationale:
This choice is the correct answer because haloperidol, an antipsychotic medication, can cause orthostatic hypotension, which leads to dizziness upon standing. Antipsychotic medications often affect blood pressure regulation and can result in a sudden drop in blood pressure when transitioning from sitting or lying down to standing. This explanation provides essential information to the client to help them understand potential side effects and take necessary precautions.
Choice B rationale:
This choice is incorrect. Haloperidol is not indicated for treating symptoms of obsessive-compulsive disorder (OCD). It is primarily used to manage symptoms of schizophrenia and other psychotic disorders. Providing false information about its indications is not appropriate and may lead to confusion.
Choice C rationale:
This choice is incorrect. Clients should never stop taking antipsychotic medications abruptly without consulting their healthcare provider. Discontinuing such medications can lead to withdrawal effects and a worsening of symptoms. Encouraging the client to stop the medication if side effects are bothersome is not appropriate and could potentially jeopardize their well-being.
Choice D rationale:
This choice is partially correct but not the best answer. While haloperidol can cause excessive salivation (sialorrhea) as a side effect, the primary concern in this situation should be related to orthostatic hypotension and dizziness upon standing. Mentioning excessive salivation would be helpful, but it's secondary to the risk of falls associated with orthostatic hypotension.
Correct Answer is ["C","D"]
Explanation
The correct answer is choice c. Believes that others are deceiving him, and choice d.Continuously holds onto grudges
Choice A rationale:
Perceiving oneself as inferior to others is more characteristic of avoidant personality disorder, where individuals often avoid social situations due to feelings of inadequacy and fear of rejection.
Choice B rationale:
Desiring to be the center of attention is a trait often seen in histrionic personality disorder, where individuals crave attention and may use dramatic behavior to achieve it.
Choice C rationale:
Individuals with paranoid personality disorder tend to have a pervasive and unjustified mistrust of others. They often believe that others are deceiving, exploiting, or harming them, even in the absence of evidence to support these beliefs. This mistrust is a central characteristic of this disorder.
Choice D rationale:
Continuously holding onto grudges is another hallmark feature of paranoid personality disorder. These individuals are prone to bearing grudges and being unforgiving, as they are hypersensitive to perceived slights or insults.
Choice E rationale:
Exhibiting a grandiose sense of self-importance is more characteristic of narcissistic personality disorder, where individuals have an inflated sense of their own importance and often lack empathy for others.
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