Which of the following should be the appropriate action by a nurse attempting to develop a therapeutic relationship with a client?

Engage in affectionate interactions with the client.

Promote the use of transference by the client.

Instruct the client on how they should behave.

Set limits for the relationship.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Engaging in affectionate interactions with the client is not appropriate in a therapeutic relationship. Affectionate interactions can blur the professional boundaries necessary for a therapeutic relationship and may lead to dependency or other issues that could compromise the care provided.

Choice B reason:

Promoting the use of transference by the client is not an appropriate action. Transference is a phenomenon where clients project feelings about figures from their past onto a healthcare professional. While recognizing transference is important, promoting it is not advised as it can interfere with the objectivity of care.

Choice C reason:

Instructing the client on how they should behave is not typically conducive to developing a therapeutic relationship. It may be perceived as paternalistic or authoritarian, which can undermine trust and hinder the establishment of a collaborative relationship.

Choice D reason:

Setting limits for the relationship is the correct action. Establishing clear boundaries helps maintain a professional and therapeutic relationship. It ensures that both the nurse and the client understand the expectations and limits of their interactions, which is essential for effective treatment and the client's well-being.

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Correct Answer is B

Explanation

Choice A reason:

Tachycardia, or rapid heart rate, is not commonly associated with anorexia nervosa. Instead, individuals with anorexia nervosa may experience bradycardia, or a slower-than-normal heart rate, due to decreased metabolic rate and changes in cardiac function.

Choice B reason:

Constipation is a common finding in individuals with anorexia nervosa. Due to malnutrition and decreased food intake, the gastrointestinal motility slows down, leading to constipation. Additionally, dehydration from inadequate fluid intake can exacerbate this condition.

Choice C reason:

Hyperkalemia, or high potassium levels in the blood, is not a typical finding in anorexia nervosa. More commonly, individuals with this eating disorder may experience hypokalemia, or low potassium levels, due to malnutrition and potential purging behaviors.

Choice D reason:

Metrorrhagia, or irregular uterine bleeding, is not a specific finding related to anorexia nervosa. However, individuals with this condition may experience amenorrhea, or the absence of menstruation, due to hormonal imbalances and low body weight.

A. "I haven't gotten my period yet, and all my friends have theirs." B. "There's a big pimple on my face, and I worry that everyone will notice it." C. "My parents treat me like a baby sometimes." D. "None of the kids at this school like me, and I don't like them either."

Correct Answer is D

Explanation

Choice A Reason:

The comment "I haven't gotten my period yet, and all my friends have theirs" reflects a common concern among adolescents regarding physical development and peer comparison. While this can cause anxiety, it is generally a normal part of adolescent development. The nurse can reassure the adolescent that the timing of puberty varies widely and that it is normal to develop at a different pace than peers.

Choice B Reason:

The concern about a pimple on the face, "There's a big pimple on my face, and I worry that everyone will notice it," is typical of adolescent worries about appearance and self-esteem. While it is important to address these concerns and provide support, it is not as urgent as addressing potential social isolation or mental health issues.

Choice C Reason:

The statement "My parents treat me like a baby sometimes" indicates a common struggle for independence among adolescents. This issue can be addressed through family counseling and communication strategies to help the adolescent and parents navigate this developmental stage. However, it does not indicate an immediate risk to the adolescent's well-being.

Choice D Reason:

The comment "None of the kids at this school like me, and I don't like them either" is the most concerning and should be the nurse's priority. This statement suggests social isolation and potential feelings of depression or low self-esteem. Social isolation can have significant negative impacts on an adolescent's mental health and development. It is crucial for the nurse to explore this further, provide support, and possibly refer the adolescent to a mental health professional.

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Which of the following should be the appropriate action by a nurse attempting to develop a therapeutic relationship with a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following findings should a nurse expect when assessing an adolescent female client with anorexia nervosa?

Correct Answer is B

Explanation

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

Correct Answer is D

Explanation

A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?

A nurse is caring for a client diagnosed with schizophrenia. The client states, "Did you know that I am engaged to the Prince of England?" The nurse should document that the client is experiencing which of the following types of delusions?

A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)

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