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 B
Explanation
Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.
The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.
Incorrect:
A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.
D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.
Correct Answer is C
Explanation
When a client is involuntarily admitted to a mental health unit, there is typically a specific time frame, such as 72 hours, during which they can be held involuntarily for evaluation and
treatment. At the end of this initial hold period, further determination is required to determine if continued hospitalization is necessary.
The primary consideration for extending the client's stay is whether they continue to pose a danger to themselves or others. This determination is based on a comprehensive assessment of the client's mental state, behavior, and potential for harm. If the client still exhibits signs of being a threat to themselves or others, the healthcare team may decide to continue their hospitalization to ensure their safety and the safety of others.
The other options listed are not the primary criteria for determining the need for continued hospitalization:
● Whether the client is unwilling to accept that treatment is needed: While the client's willingness to accept treatment is an important factor, it is not the sole determinant for extending their stay. Even if the client recognizes the need for treatment, if they are still a danger to themselves or others, their hospitalization may be prolonged.
● Whether the client is financially incapable of paying for prescribed medications: Financial considerations do not directly impact the decision to extend the client's stay. The focus is on their safety and the need for continued psychiatric assessment and treatment.
● Whether the client is unable to make arrangements to stay with someone: The client's living arrangements or ability to stay with someone outside of the hospital are not the main factors in determining the need for extended hospitalization. The key consideration is whether the client continues to pose a danger to themselves or others.
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