Nokea
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.
You may also like to solve these questions
A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider?
- A. Hemoglobin 16 g/dL.
- B. WBC Count 8,000/mm3.
- C. RBC Count 4.9 million/mm².
- D. Platelets 100,000/mm3.
Correct Answer: D
Rationale: The correct answer is D: Platelets 100,000/mm3. This result is concerning as clonazepam can potentially cause thrombocytopenia, leading to a decreased platelet count. Thrombocytopenia can increase the risk of bleeding, which is crucial to monitor in clients taking this medication.
A: Hemoglobin 16 g/dL - This result is within the normal range and not directly related to clonazepam use.
B: WBC Count 8,000/mm3 - This result is within the normal range and not directly related to clonazepam use.
C: RBC Count 4.9 million/mm² - This result is within the normal range and not directly related to clonazepam use.
A nurse in a mental health facility is reviewing the laboratory results of a client who is taking lithium carbonate. Which of the following findings places the client at risk for lithium toxicity?
- A. Aspartate aminotransferase 40 units/L.
- B. WBC 6,000/mm3.
- C. Sodium 132 mEq/L.
- D. Calcium 10.0 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Sodium 132 mEq/L. Low sodium levels can increase the risk of lithium toxicity as both sodium and lithium compete for reabsorption in the renal tubules. This can lead to increased lithium levels in the blood, potentially causing toxicity.
A: Aspartate aminotransferase within normal range, not directly related to lithium toxicity.
B: WBC within normal range, not directly related to lithium toxicity.
D: Elevated calcium levels do not directly increase the risk of lithium toxicity.
A nurse is assessing a patient with major depressive disorder (MDD). Which assessment tool can the nurse use to measure the severity and impact of depression on the patient's functioning?
- A. GAD-7
- B. BAI
- C. PHQ-9
- D. CAGE
Correct Answer: C
Rationale: The correct answer is C: PHQ-9. The Patient Health Questionnaire-9 is specifically designed to assess the severity of depressive symptoms and their impact on daily functioning in individuals with MDD. It consists of 9 questions that cover core symptoms of depression such as low mood, loss of interest, and concentration difficulties. The PHQ-9 is widely used in clinical settings and has been validated as a reliable tool for screening and monitoring depression.
Choice A (GAD-7) is used to assess generalized anxiety disorder, not depression. Choice B (BAI) is the Beck Anxiety Inventory, which measures anxiety symptoms, not depression. Choice D (CAGE) is a tool for screening alcohol use disorder, not depression.
In summary, the PHQ-9 is the most appropriate assessment tool for measuring the severity and impact of depression in a patient with MDD, as it is specifically designed for this purpose and has been validated for use in clinical settings.
A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?
- A. Blood pH 7.60
- B. BUN 21 mg/dL
- C. +2 edema of the lower extremities
- D. Lanugo covering the body
Correct Answer: A
Rationale: The correct answer is A: Blood pH 7.60. A pH of 7.60 indicates alkalosis, which can lead to serious complications like cardiac arrhythmias. The nurse should intervene immediately by informing the healthcare provider and implementing measures to correct the pH imbalance.
B: BUN 21 mg/dL is within the normal range and does not require immediate intervention.
C: +2 edema of the lower extremities is a common finding in clients with anorexia nervosa but does not warrant immediate intervention unless it is severe or worsening.
D: Lanugo covering the body is a common symptom in clients with anorexia nervosa and does not require immediate intervention.
In summary, the other choices are not as critical as a significantly elevated blood pH level, which can lead to life-threatening complications.
A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?
- A. Obtain consent from the client's family member
- B. Inform the client that they have the legal right to refuse treatment at any time
- C. Request another nurse to review the procedure with the client
- D. Encourage the client to have the procedure
Correct Answer: B
Rationale: Correct Answer: B - Inform the client that they have the legal right to refuse treatment at any time.
Rationale: It is crucial for the nurse to respect the client's autonomy and right to make decisions about their own healthcare. By informing the client of their legal right to refuse treatment, the nurse empowers the client to make an informed choice. This approach upholds the principles of beneficence and non-maleficence by promoting the client's well-being and avoiding potential harm from a procedure the client does not want.
Incorrect Choices:
A: Obtaining consent from the client's family member is not appropriate as the client has the capacity to make their own decisions.
C: Requesting another nurse to review the procedure does not address the client's autonomy and right to refuse treatment.
D: Encouraging the client to have the procedure goes against the client's expressed wishes and autonomy.