A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.

A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.

B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.

C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.

This statement implies that the nurse is taking sides and suggesting a specific course of action to the client. It is important for the nurse to remain neutral and non-directive during family therapy sessions. The nurse's role is to facilitate open communication, active listening, and understanding between the family members, rather than imposing their own opinions or suggesting specific solutions.

To ensure a therapeutic and unbiased approach, the nurse should intervene and provide feedback to the newly licensed nurse, reminding them to maintain a neutral stance and encourage the client to explore their own perspectives and feelings about the relationship.

Incorrect:

A. "We should invite your partner to be a part of our discussion." This statement suggests involving the partner, which is a common practice in family therapy. It recognizes the importance of including all relevant family members in the therapeutic process.

B. "Tell me about the concerns that you have regarding your relationship." This statement encourages the client to express their concerns and provides an opportunity for them to share their thoughts and feelings about the relationship. It promotes open communication and active listening.

D. "Relationship difficulties are stressful and require effort to resolve." This statement acknowledges the challenges in relationships and emphasizes the need for active participation and effort to address and resolve issues. It sets a realistic expectation for the client and supports their engagement in the therapeutic process.