A nurse in an acute mental health center is performing a physical assessment on a client. Which of the following findings should the nurse document under the integumentary system? (Select all that apply.)
Numbness
Skeletal deformities
Alopecia
Ecchymosis
The Correct Answer is A
A. Transference: Transference occurs when a client projects feelings about someone from their past onto the therapist or nurse. The client’s feelings about the nurse being similar to their mother fit this description.
B. Confrontation: Confrontation involves addressing discrepancies or issues directly, which is not the focus here. The situation described is about the client’s feelings towards the nurse.
C. Countertransference: Countertransference occurs when a nurse or therapist has emotional reactions based on their own past experiences, not the client’s feelings about the nurse.
D. Incongruence: Incongruence refers to a mismatch between a person's experiences and their self-concept. The situation described involves the client's feelings toward the nurse rather than incongruence.
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Correct Answer is D
Explanation
A. "Why do you think you might have cancer when your diagnosis is a benign condition?" This response is not therapeutic as it questions the client’s concerns in a dismissive manner and could increase anxiety.
B. "I think that's something you need to discuss further with your doctor." This response deflects the issue to the doctor and does not provide immediate support or acknowledgment of the client's feelings.
C. "I have reviewed your history and I don't see any reason for you to worry about that." This response may minimize the client’s concerns and does not address the client's emotional state effectively.
D. "I'm hearing that you are concerned that you could have cancer."This is the most therapeutic response as it acknowledges the client’s fears and provides an opportunity for further discussion and emotional support.
Correct Answer is D
Explanation
A. Guided imagery: Guided imagery involves creating mental images to promote relaxation, not applicable here.
B. Orientation to reality: Reality orientation involves correcting misperceptions about time, place, and person, not used in this context.
C. Remotivation: Remotivation involves stimulating a client's interest in the environment and is not applicable here.
D. Validation: Correct. Validation acknowledges the client's feelings and emotions, supporting their sense of reality.
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