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
When planning an interview for a newly admitted client and deciding who to include, the nurse should use the method of including people whom the client views as family. It is important to consider the client's perception and definition of family, as this can vary from person to person. Family can include not only blood relatives or individuals related by marriage but also those who have significant emotional connections and provide support to the client.
Incorrect:
A. Including people who can support the client adequately: While it is essential to include individuals who can provide support to the client, support can come from various sources beyond family members. Including only those who can support the client adequately may exclude important individuals in the client's life who are not considered family but still play a significant role.
B. Including people who live in the same house with the client: While individuals living in the same house as the client may have daily interactions and involvement in the client's life, they may not necessarily be considered family by the client. It is crucial to consider the client's perception of family and include individuals based on that definition.
D. Including people who are related to the client by blood and marriage: While blood relatives and individuals related by marriage can be part of the client's family, limiting the inclusion to only these individuals may exclude others who are important to the client's support system.
Correct Answer is B
Explanation
Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.
A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.
C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.
D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.
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