Patty is admitted to the inpatient unit after she has cut her wrists. Which is the most important nursing intervention?

Choice A Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. It is not directly related to involving a third person in conflicts.

Choice B Reason:

Scapegoating is incorrect. Scapegoating involves blaming one family member for the family's problems. While this can be a dysfunctional family dynamic, it is not specifically about involving a third person in conflicts.

Choice C Reason:

Double Binding is incorrect. Double binding involves conflicting messages that create a no-win situation for the recipient. It does not specifically involve the inclusion of a third person in conflicts as observed in the given scenario.

Choice D Reason:

Triangulation is correct. Triangulation in family systems therapy occurs when a third person, often a child, is involved in the conflicts between two other family members. In this scenario, Kate is venting her frustrations to her younger son, which creates a triangle or three-person dynamic in the family system. Triangulation can serve as a way for family members to stabilize their relationships by shifting the focus or tension onto a third party.

Choice A Reason:

Engaging in friendly interactions with the client is correct. Developing a therapeutic relationship involves creating a supportive and empathetic connection with the client. Engaging in friendly interactions helps build trust and rapport. This approach fosters a positive environment for communication and collaboration.

Choice B Reason:

Instructing the client on how he should behave is incorrect. Instructing the client on how to behave can be perceived as directive and may hinder the development of a collaborative and trusting relationship.

Choice C Reason:

Setting limits for the relationship is incorrect. While setting boundaries is important, using the term "limits" can convey a sense of restriction. It's crucial to establish appropriate boundaries, but the term "limits" may not promote the openness needed in a therapeutic relationship.

Choice D Reason:

Promoting the use of transference by the client is incorrect. Promoting transference involves encouraging the client to project feelings from past relationships onto the nurse. This is generally not considered a therapeutic approach and may lead to misunderstandings in the therapeutic relationship.