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. Dialectical behavior therapy. Dialectical behavior therapy is primarily used for borderline personality disorder, focusing on emotional regulation, distress tolerance, and mindfulness. It is not the primary therapy for avoidant personality disorder.
B. Antipsychotic medications. Antipsychotic medications are typically used to manage symptoms of psychotic disorders such as schizophrenia. Avoidant personality disorder does not involve psychosis and is better managed with psychotherapy.
C. Interpersonal therapy. Interpersonal therapy is beneficial for avoidant personality disorder as it focuses on improving social skills, self-esteem, and communication. This therapy helps clients develop healthier relationships and overcome fears of rejection.
D. Antidepressant medications. While antidepressants may be used to treat co-occurring conditions such as depression or anxiety, they do not directly address the core features of avoidant personality disorder. Psychotherapy remains the primary treatment.
Correct Answer is B
Explanation
A. Being in a family with numerous siblings. While family dynamics can influence mental health, having multiple siblings does not inherently increase the risk for mental illness. Protective factors such as social support from siblings may actually be beneficial.
B. Early exposure to violence. Experiencing violence at a young age, such as abuse or witnessing traumatic events, can increase the risk for mental illness by altering stress responses, emotional regulation, and cognitive development.
C. Being raised by a single mother. While single-parent households may present challenges, they do not directly cause mental illness. Supportive parenting, economic stability, and social resources can mitigate potential stressors.
D. Living in a rural area. Although access to mental health care may be more limited in rural areas, residing in such an environment is not a direct risk factor for developing mental illness. Social support and lifestyle factors play a more significant role.
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