Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

"You should try to see your partner's point of view before your own."

"Tell me more about the concerns that you have regarding your marriage."

"We could develop a plan for how to talk about this with your partner."

"Relationship difficulties are stressful and require effort to resolve."

Answer and Explanation

The Correct Answer is A

Choice A reason:

This statement may require intervention by the charge nurse because it suggests the nurse is taking a directive approach, potentially overstepping professional boundaries. It implies that the client's perspective is less important than their partner's, which could undermine the therapeutic relationship and the client's sense of autonomy.

Choice B reason:

Asking the client to elaborate on their concerns is a therapeutic communication technique that encourages expression and exploration of feelings. It does not require intervention as it is supportive and facilitates the nurse-client relationship.

Choice C reason:

Offering to help the client develop a plan to discuss their concerns with their partner is a constructive approach that empowers the client. It promotes problem-solving and does not necessitate intervention by the charge nurse.

Choice D reason:

Acknowledging that relationship difficulties are stressful and require effort to resolve is an empathetic statement that validates the client's experience. It is supportive and does not require intervention.

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Correct Answer is D

Explanation

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.

A. The client responds to questions with disorganized speech. B. The client has lost interest in sexual relations. C. The client reports that voices are telling him to write a novel. D. The client's spouse reports that the client has recently gained weight.

Correct Answer is A

Explanation

Choice A Reason:

Disorganized speech is a common symptom of acute mania in bipolar disorder. It reflects the racing thoughts and the inability to filter or organize ideas before speaking. This symptom can manifest as rapidly changing topics, speaking incoherently, or displaying a flight of ideas.

Choice B Reason:

While changes in interest in sexual relations can occur in bipolar disorder, a loss of interest is more commonly associated with depressive episodes rather than manic episodes. During manic episodes, individuals may actually exhibit an increased interest in sexual activity.

Choice C Reason:

Hearing voices, or auditory hallucinations, can be a symptom of acute mania, especially if the content of the hallucinations is grandiose or related to the individual's inflated self-esteem or sense of importance. However, this symptom is not as common as disorganized speech and is more often associated with psychotic features.

Choice D Reason:

Weight gain is not a symptom typically associated with acute mania. In fact, during manic episodes, individuals may experience weight loss due to high energy levels, decreased need for sleep, and increased physical activity.

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Which of the following statements by the nurse requires intervention by the charge nurse when a client is sharing concerns about their marriage?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?

Correct Answer is A

Explanation

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