A nurse manager and a newly licensed nurse are engaged in an interview with a client. The newly licensed nurse tells the client, "You look like my sister. I love my sister and would do anything for her." Which of the following actions should the nurse manager take?

Inform the newly licensed nurse that they are successfully building trust and rapport.

Ask the newly licensed nurse if they are comfortable providing care to the client.

Record that the newly licensed nurse is able to maintain professional nurse-client boundaries.

Assign the newly licensed nurse to a different client.

Answer and Explanation

The Correct Answer is D

A. Inform the newly licensed nurse that they are successfully building trust and rapport. While therapeutic communication is essential, personalizing the interaction in this way crosses professional boundaries. Comparing a client to a family member can create unrealistic expectations and blur the nurse-client relationship. Maintaining professional distance ensures objective and ethical care.
B. Ask the newly licensed nurse if they are comfortable providing care to the client. While assessing a nurse’s comfort level is important, it does not address the boundary violation. The concern is not about the nurse's comfort but about maintaining professionalism in client interactions. Direct intervention is needed to correct the inappropriate statement and reinforce professional conduct.
C. Record that the newly licensed nurse is able to maintain professional nurse-client boundaries. The statement made by the newly licensed nurse demonstrates a boundary issue rather than professionalism. Nurses should establish rapport without over-identification with clients. Documenting that the nurse maintained boundaries would be inaccurate and fail to address the issue.
D. Assign the newly licensed nurse to a different client. The statement suggests an emotional attachment that may interfere with objective care. Reassigning the nurse prevents further boundary issues and allows for education on maintaining professionalism. Ensuring appropriate nurse-client relationships promotes ethical practice and patient-centered care.

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Correct Answer is C

Explanation

A. Seeking a tutor for help with a challenging class. Seeking academic support is a positive coping strategy and does not indicate a risk for suicide. Students struggling with schoolwork may experience stress, but tutoring reflects problem-solving behavior and a willingness to improve academically.
B. Volunteering to serve food at a homeless shelter over the holidays. Engaging in community service is generally a sign of social involvement and purpose. While sudden changes in behavior could be concerning, volunteering itself is not a warning sign of suicide and may indicate a sense of fulfillment.
C. Displaying extreme mood swings. Extreme mood swings can indicate emotional instability, a key warning sign of suicide. Drastic changes in mood, especially from deep sadness to sudden calmness, may suggest suicidal intent and should be taken seriously by caregivers and peers.
D. Making plans to go to the prom. Making future plans typically reflects hope and engagement in life. However, if a student suddenly makes farewell plans, withdraws from social activities, or gives away belongings, it may be a concerning sign that requires further assessment.

A. Cognitive behavioral therapy B. Vagal nerve stimulation C. Electroconvulsive therapy D. Deep-brain stimulation

Correct Answer is A

Explanation

A. Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a noninvasive treatment that helps individuals with depression by identifying and modifying negative thought patterns and behaviors. It is widely used and effective in improving mood, coping skills, and overall mental well-being.
B. Vagal nerve stimulation. Vagal nerve stimulation (VNS) is an invasive procedure that involves implanting a device to stimulate the vagus nerve. It is used for treatment-resistant depression and is not considered a first-line, noninvasive option.
C. Electroconvulsive therapy. Electroconvulsive therapy (ECT) is a medical procedure that involves electrical stimulation of the brain under anesthesia. Although effective for severe depression, it is invasive and typically reserved for cases that do not respond to medication or therapy.
D. Deep-brain stimulation. Deep-brain stimulation (DBS) involves surgically implanting electrodes in specific brain regions to regulate mood-related neural activity. It is an invasive treatment used in research or for severe, treatment-resistant depression.

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A nurse manager and a newly licensed nurse are engaged in an interview with a client. The newly licensed nurse tells the client, "You look like my sister. I love my sister and would do anything for her." Which of the following actions should the nurse manager take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school nurse is assisting in the planning a presentation on identifying potential warning signs of suicide for high school students. Which of the following examples of behaviors should the nurse include in the presentation?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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