A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?
"I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior."
"I'm curious as to why you are behaving this way. Can you please explain it to me?"
"I'm very flattered, but I am married and cannot engage in this behavior."
"I am going to leave now and I'll return in one hour to spend time with you then."
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief.
Let's review the other options and explain why they are not the most appropriate responses:
A. "Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder the
nurse-client relationship.
B. "I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.
D. "Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful and non-judgmental attitude.
Correct Answer is A
Explanation
Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.
Incorrect:
B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.
C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.
D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.
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