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A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
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A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following actions should be included in the plan of care?
- A. Allow manipulation so as to not raise the client’s anxiety.
- B. Avoid discussing past behaviors with the client.
- C. Bargain with the client to discourage manipulative behavior.
- D. Set clear and consistent limits on manipulative behaviors.
Correct Answer: D
Rationale: The correct answer is D: Set clear and consistent limits on manipulative behaviors. By setting clear boundaries, the nurse establishes a structured environment that promotes accountability and helps the client understand appropriate behavior. This method reinforces boundaries and helps the client learn to interact in a healthier way.
Explanation for other choices:
A: Allowing manipulation does not address the underlying issue and may enable further manipulative behavior.
B: Avoiding discussing past behaviors hinders the therapeutic process and may prevent understanding and resolution of manipulative tendencies.
C: Bargaining with the client only reinforces manipulative behavior and does not address the root cause.
In summary, setting clear and consistent limits is the most effective approach in managing manipulative behavior.
A nurse is caring for a client who is receiving treatment for alcohol withdrawal. Which of the following findings is the highest priority?
- A. Vitamin deficiency
- B. Diaphoresis
- C. Tremors
- D. Visual hallucinations
Correct Answer: D
Rationale: The correct answer is D: Visual hallucinations. Visual hallucinations in a client undergoing alcohol withdrawal indicate severe withdrawal symptoms and potential progression to delirium tremens, a life-threatening condition. Addressing visual hallucinations promptly is crucial to prevent harm or injury to the client. Vitamin deficiency (choice A), diaphoresis (choice B), and tremors (choice C) are common symptoms of alcohol withdrawal but are not as immediately life-threatening as visual hallucinations. Therefore, addressing visual hallucinations takes priority over these symptoms.
A nurse is teaching a newly licensed nurse about reporting suspected child abuse. Which of the following statements indicates an understanding by the newly licensed nurse?
- A. "Evidence must exist prior to reporting."
- B. "If the potential abuser commits to stopping the abuse, health care workers are not required to report it."
- C. "I don't want to defame someone if the report is false."
- D. "If suspicion of abuse exists, then reporting is mandatory."
Correct Answer: D
Rationale: The correct answer is D: "If suspicion of abuse exists, then reporting is mandatory." This statement is correct because as a healthcare professional, it is crucial to report any suspicion of child abuse to protect the child's safety. Reporting is mandatory to ensure that appropriate actions are taken to investigate and prevent harm to the child.
A: "Evidence must exist prior to reporting." - This statement is incorrect because suspicion alone is enough to trigger reporting, and waiting for evidence may delay intervention and put the child at risk.
B: "If the potential abuser commits to stopping the abuse, health care workers are not required to report it." - This statement is incorrect as it is the responsibility of healthcare workers to report suspected abuse regardless of promises made by the potential abuser.
C: "I don't want to defame someone if the report is false." - This statement is incorrect because the focus should be on the safety and well-being of the child, and reporting suspicions of abuse is not about def