The nurse is caring for a patient who consults with family members before making every treatment decision. Based on the nurse's observation. which type of boundary exists within the family structure?

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.

Choice A Reason:

Grooming is correct. Grooming assesses the client's personal care and hygiene, providing insight into their ability to perform self-care activities.

Choice B Reason:

Long-term memory is correct. Evaluating long-term memory helps assess the client's ability to recall past events and information, which can be affected in individuals with dementia.

Choice C Reason:

Support systems is incorrect. While support systems are crucial in the overall care of individuals with dementia, they are not typically assessed in a traditional MSE.

Choice D Reason:

Affecting is correct. Affect refers to the client's emotional expression. Assessing affect helps in understanding the client's emotional state, which can be important in diagnosing and managing dementia.

Choice E Reason:

Presence of pain is incorrect. While assessing pain is essential in clinical care, it may be more pertinent to a physical assessment than a mental status examination specifically focused on cognitive functioning.