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A charge nurse is discussing the care of a client who has a substance use disorder with a staff nurse. Which of the following statements by the staff nurse should the charge nurse identify as countertransference?
- A. The client asked me to go on a date with him but I refused
- B. The client needs to accept responsibility for his substance use
- C. The client is just like my brother who finally overcame his habit
- D. The client generally shares his feelings during group therapy sessions
Correct Answer: C
Rationale: The correct answer is C. Countertransference occurs when a healthcare provider projects their own feelings or experiences onto a client. In this case, the staff nurse comparing the client to their brother who overcame addiction demonstrates a personal connection that may affect their ability to provide unbiased care. This can lead to potential issues in therapeutic boundaries and compromise the client's care.
A: This choice does not involve countertransference as it simply describes a professional boundary being maintained.
B: This choice focuses on the client's responsibility and does not involve the nurse's personal feelings or experiences.
D: This choice indicates a positive interaction during therapy sessions and does not demonstrate countertransference.
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A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?
- A. Command hallucinations
- B. Impaired memory
- C. Inappropriate speech patterns
- D. Rapid mood swings
Correct Answer: A
Rationale: The correct answer is A: Command hallucinations. This finding requires immediate intervention as it poses a risk of harm to the client or others. Command hallucinations can lead to dangerous behaviors if the client acts on them. Impaired memory (B), inappropriate speech patterns (C), and rapid mood swings (D) are common symptoms of delirium but do not pose an immediate threat of harm. It is crucial for the nurse to address the command hallucinations promptly to ensure the safety and well-being of the client and others.
A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
- A. Stop the newly licensed nurse from administering the medication
- B. Assess the need for physical restraints
- C. Demonstrate how to verbally de-escalate the situation
- D. Discuss the purpose of the medication with the client
Correct Answer: A
Rationale: The correct answer is A: Stop the newly licensed nurse from administering the medication. This is the first action the nurse manager should take as the client is refusing the medication and is in a manic state, which may affect their decision-making capacity. It is important to prioritize the client's autonomy and safety by ensuring that the medication is not administered against their will. Assessing for physical restraints (B) should not be the first step as it may escalate the situation and compromise the client's dignity. Demonstrating verbal de-escalation techniques (C) and discussing the purpose of the medication with the client (D) are important interventions but should come after ensuring the immediate safety of the client by stopping the medication administration.
A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
- A. Snap a rubber band on your wrist when you think about checking the locks
- B. Keep a journal of how often you check the locks each night
- C. Focus on abdominal breathing whenever you go to check the locks
- D. Ask a family member to check the locks for you at night
Correct Answer: A
Rationale: The correct answer is A: Snap a rubber band on your wrist when you think about checking the locks. This instruction aligns with the thought stopping technique, which aims to interrupt obsessive thoughts. By associating the thought of checking locks with a physical sensation like snapping a rubber band, the client can disrupt the urge to check repeatedly. This technique helps the client become more aware of their thoughts and behaviors, ultimately reducing the compulsive checking behavior.
Other choices are incorrect because:
B: Keeping a journal may increase the client's focus on the behavior rather than interrupting it.
C: Focusing on breathing does not directly address the obsessive thought about locking doors.
D: Depending on a family member does not empower the client to manage their own behavior.
A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?
- A. The client has several siblings
- B. The client's father lives in the client's home
- C. The client's mother has asthma
- D. The client is the oldest of their siblings
Correct Answer: B
Rationale: The correct answer is B: The client's father lives in the client's home. This is a contributing factor to the development of conduct disorder because the presence of a parent figure in the home provides stability and guidance for the child. When a father figure is absent, it can lead to a lack of discipline, role modeling, and emotional support, which are crucial for a child's development. Choices A, C, and D are incorrect as they do not directly relate to family dynamics and do not address the impact of parental presence on the development of conduct disorder.
A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?
- A. Offer the client advice about various treatment choices
- B. Discourage the client from forming new relationships
- C. Allow the client unlimited time for the grieving process
- D. Change the subject when the client becomes upset
Correct Answer: C
Rationale: The correct answer is C: Allow the client unlimited time for the grieving process. This option is appropriate because receiving a terminal cancer diagnosis is a significant emotional event that requires time for processing and grieving. The nurse should provide emotional support and create a safe space for the client to express their feelings without rushing them. This approach promotes therapeutic communication and helps the client cope with the diagnosis.
Option A (Offer the client advice about various treatment choices) is incorrect because the client has received a terminal diagnosis, so treatment choices may not be applicable. Option B (Discourage the client from forming new relationships) is incorrect as forming relationships can be a source of support and comfort for the client. Option D (Change the subject when the client becomes upset) is incorrect because it dismisses the client's emotions and does not address their needs effectively.