A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?
Refusing to participate in group activities
Talking negatively about other staff members
Expressing frustration regarding unit rules
Reacting to the nurse as though she were his mother
The Correct Answer is D
Transference is a defense mechanism in which the client unconsciously transfers feelings, attitudes, or impulses from a past relationship to a current one, such as a health care provider. The nurse should recognize this behavior and maintain professional boundaries with the client. The other options are not specific to transference and may indicate other issues.
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Correct Answer is B
Explanation
Choice A reason:
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
Choice B reason:
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
Choice C reason:
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
Choice D reason:
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
Correct Answer is A
Explanation
The client's statement reflects a realistic and positive attitude toward recovery and a decrease in perfectionism, which is a common trait among clients with anorexia nervosa. Following cooking blogs may indicate an unhealthy obsession with food and calories. A BMI of 14 is still below the normal range of 18.5 to 24.9 and indicates severe malnutrition. A potassium level of 3.2 mEq/L is below the normal range of 3.5 to 5.0 mEq/L and indicates electrolyte imbalance.
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