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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. "Persistent depressive disorder is a mild chronic form of depression." PDD, previously known as dysthymia, is a long-lasting depressive condition with persistent low mood for at least two years. Symptoms are less severe than major depressive disorder but are continuous and can significantly impact daily life. While not as acute as major depression, PDD requires management through therapy, medication, and lifestyle modifications.
B. "Persistent depressive disorder is characterized by delusions and hallucinations." Psychotic features such as delusions and hallucinations are not typical of persistent depressive disorder (PDD). These symptoms are more commonly associated with major depressive disorder with psychotic features or schizophrenia. PDD primarily involves chronic low-grade depression rather than severe psychotic symptoms.
C. "Persistent depressive occurs shortly after taking or withdrawing from a substance." Substance-induced depressive disorder is a distinct diagnosis that results from drug use or withdrawal. Persistent depressive disorder is not caused by substance use but is a long-term mood disorder that lasts for at least two years. The symptoms are chronic and not directly linked to substance intake or withdrawal.
D. "Persistent depressive is characterized by both manic and depressive episodes." Bipolar disorder, not persistent depressive disorder, is characterized by alternating manic and depressive episodes. PDD involves a chronic, low-level depressive state without manic symptoms. Individuals with PDD may experience periods of worsening depression, but they do not exhibit the high-energy or euphoric states seen in bipolar disorder.
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