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?

Diffuse

Clear

Differentiation

Rigid

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Diffuse is correct. In a diffuse or permeable family boundary, there is a lack of clear separation between family members. Decisions and responsibilities may be shared extensively, and individual autonomy is limited. The patient's behavior of consulting with family members before making treatment decisions suggests a diffuse boundary where decision-making involves significant input from various family members.

Choice B Reason:

Clear is incorrect. - In a clear or rigid boundary, there is a distinct separation between family members, and individual autonomy is highly emphasized. The described behavior does not align with a clear boundary.

Choice C Reason:

Differentiation is incorrect. Differentiation refers to the ability of family members to maintain their individuality while remaining emotionally connected. The behavior described is more indicative of a diffuse boundary than a differentiation issue.

Choice D Reason:

Rigid is incorrect. A rigid boundary is characterized by strict rules and limited flexibility. The described behavior does not align with a rigid boundary where decision-making might be more centralized and less consultative.

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Correct Answer is B

Explanation

A. Building a trusting relationship:Establishing trust is essential in therapeutic relationships, especially with clients at risk for self-harm. However, ensuring the client’s immediate safety by searching belongings takes precedence to protect the client from further harm.

B. Searching her belongings:This is the first priority to ensure Patty’s immediate safety and prevent access to any objects she could use to harm herself. This action addresses the immediate risk and creates a safer environment for her.

C. Orienting her to the unit. Orientation to the unit helps the client feel more comfortable and understand the rules and layout of the facility, but it is not as urgent as ensuring her safety upon admission.

D. Helping her settle into her room:Assisting Patty in getting comfortable is important for her overall well-being but is secondary to securing her environment by removing any potentially harmful items.

A. in the orientation phase B. On the working phase C. when the patient brings up the topic D. in the termination phase

Correct Answer is D

Explanation

Choice A Reason:

In the orientation phase is false. The orientation phase is focused on establishing rapport, building trust, and identifying the patient's needs and goals. It is too early to discuss termination during this phase.

Choice B Reason:

On the working phase is false. The working phase involves active problem-solving, goal attainment, and skill development. While progress is being made, it is not the appropriate time to introduce the topic of termination.

Choice C Reason:

When the patient brings up the topic is false. While it's important to be responsive to the patient's concerns, addressing the issue of termination solely based on the patient's initiation may not provide a comprehensive and planned discussion. The nurse should guide the conversation about termination at the appropriate time, considering the progress made in therapy.

Choice D Reason:

The termination phase is the final phase of the therapeutic relationship, and it involves discussing and planning for the conclusion of the therapeutic alliance. It provides an opportunity for the nurse and patient to reflect on the progress made, revisit goals, and discuss strategies for maintaining gains after the conclusion of the formal therapeutic relationship.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

During a therapeutic nurse-patient relationship, when would the nurse plan to first address the issue of termination?

Correct Answer is D

Explanation

Peplau's Interpersonal Theory of Nursing: Select one:

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