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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
"Your provider usually recommends a diaphragm and spermicidal cream." This response prescribes a specific method without considering the client's preferences, health history, or individual needs. It's important to involve the client in the decision-making process and discuss various contraceptive options.
Choice B Reason:
"It's your choice, of course, but birth control pills are the most reliable." This response might pressure the client toward a specific method and may not consider other factors such as the client's preference, medical history, or potential side effects. It's essential to provide information and support rather than directing the client to a particular choice.
Choice C Reason:
"I’d consider an intrauterine device. You won't have to worry about pregnancy. “Similar to the first option, this response recommends a specific method without a thorough discussion of the client's preferences, health considerations, or individual needs. It's important to explore various options collaboratively with the client.
Choice D Reason:
"Let's talk about the available options and go from there. “This response is patient-centered and encourages collaborative decision-making. It allows the nurse to discuss various contraceptive methods, considering the client's preferences, health history, and individual needs. It supports shared decision-making between the nurse and the client.
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.
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