If a client demonstrates transference towards the nurse, how should the nurse respond?

Encourage the client to ignore these thoughts and feelings.

Promote safety and immediately terminate the relationship with the client.

Immediately reassign the client to another staff member.

Help the client to clarify the meaning of the relationship, based on the present situation.

Answer and Explanation

The Correct Answer is D

a. Encourage the client to ignore these thoughts and feelings: This invalidates the client's experience and might hinder the therapeutic relationship.
b. Promote safety and immediately terminate the relationship with the client: Termination is a last resort, and transference can be a valuable tool for therapy if addressed constructively.
c. Immediately reassign the client to another staff member: This avoids the issue and doesn't address the underlying cause of transference.
d. Help the client to clarify the meaning of the relationship, based on the present situation. (Correct) Transference is a phenomenon where a client unconsciously redirects emotions and feelings from significant figures in their past onto the nurse. A therapeutic response involves acknowledging these feelings and helping the client explore them in a safe and supportive environment

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Correct Answer is B

Explanation

a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.

A. Blood pressure 110/70 B. heart rate 86 C. Hypoactive bowel sounds D. Increased restlessness E. Negative Homan's sign

Correct Answer is ["D"]

Explanation

a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.

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If a client demonstrates transference towards the nurse, how should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

The nurse is assessing the status of a post-operative client in the PACU. The nurse should be most concerned with which assessment finding?

Correct Answer is ["D"]

Explanation

A client, who was diagnosed with Post Traumatic Stress Disorder (PTSD), is now experiencing flashbacks and is displaying irritable behavior. The nurse would:

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A client has recently been diagnosed with Alzheimer's disease. Which medication would the nurse expect the physician to order for this client's cognitive impairment?

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