The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?
A lot of clients behave that way, but you cannot take it personally.
Have you tried to establish a therapeutic relationship with the clients?
Do you want me to assign another nurse?
Clients often behave that way when they are in pain.
The Correct Answer is B
Choice A reason:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.
Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.
Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.
Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.
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Correct Answer is B
Explanation
Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.
Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.
Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.
Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.
Correct Answer is D
Explanation
Choice A reason:
Agreeing to send the information without the client’s consent is a breach of confidentiality. Healthcare providers must protect patient privacy and cannot disclose medical information without explicit permission from the client.
Choice B reason:
While obtaining the client’s signed consent is necessary before releasing information, this response still acknowledges that the person in question is a client, which could be a breach of confidentiality.
Choice C reason:
Stating that the information cannot be given out is correct, but it still indirectly confirms that the person is a client, which could be a breach of confidentiality.
Choice D reason:
“I am unable to acknowledge whether or not your employee is a client on this unit” is the most appropriate response. This statement protects the client’s privacy by not confirming or denying their presence in the unit, thus maintaining confidentiality.