A nurse is interviewing a client who has a personality disorder. The nurse and client have agreed on an interview time, but the client resists discussing her feelings until 5 minutes prior to the end of the session and then asks for additional time. Which of the following actions should the nurse take?
Extend the scheduled time, as the client is finally able to discuss important feelings.
End at the scheduled time, telling the client that he can continue at the next scheduled session.
Arrange for another nurse to continue the interview.
Set an extra meeting time to discuss the client's feelings.
The Correct Answer is B
Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.
Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.
Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.
Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.
Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.
Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.
Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.
Correct Answer is ["A","E"]
Explanation
Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.
Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.
Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.
Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.
Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.
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