Which is the best nursing action when a client demonstrates transference toward a nurse?

Correct Answer: D

Rationale: When a client demonstrates transference toward a nurse, the best nursing action is to help the client clarify the meaning of the current nurse-client relationship. Transference occurs when a client's emotions and feelings from past relationships are unconsciously projected onto the nurse. It is a common occurrence in therapeutic relationships, and addressing it can lead to greater understanding and progress in the therapeutic process. By helping the client recognize and discuss these feelings, the nurse can facilitate insight, promote trust, and strengthen the therapeutic relationship. This approach allows for a more effective exploration of the client's emotions and experiences, leading to better outcomes in the nursing care provided. Terminating the relationship, encouraging the client to ignore these feelings, or immediately reassigning the client to another staff member would not address the underlying issues and could hinder the therapeutic process.

Correct Answer: B

Rationale: Option B, "Remember, we have a professional relationship. Are you feeling uncomfortable?" is the most appropriate nursing response in this scenario. This response addresses the client's statement in a respectful and non-confrontational manner while also setting clear boundaries regarding the professional nature of the relationship. It acknowledges the client's feelings without encouraging inappropriate behavior or engaging in a romantic dialogue. Setting boundaries is important in therapeutic relationships, especially with clients who may be experiencing delusions or disorganized thinking due to conditions such as paranoid schizophrenia. By gently redirecting the conversation and reminding the client of the boundaries in the therapeutic relationship, the nurse can help maintain a safe and therapeutic environment for both the client and themselves.

Correct Answer: B

Rationale: The main goal of the working phase of the nurse-client therapeutic relationship is to work with the client to address and resolve their problems. During this phase, the nurse and client collaboratively identify issues, set goals, and work together towards achieving those goals. The focus is on exploring feelings, gaining insight, and making positive changes to promote the client's well-being. The working phase involves active listening, offering support, providing education, and implementing interventions to help the client overcome obstacles and improve their quality of life. The ultimate aim is to assist the client in resolving their problems and empowering them to make positive changes in their life.

Correct Answer: C

Rationale: C. Promoting client insight into problematic behavior: This is an essential characteristic of the nurse-client therapeutic relationship as it involves helping the client gain understanding and awareness of their maladaptive behaviors, thoughts, or patterns. By promoting client insight, the nurse can support the client in making positive changes and progress towards improved mental health.

Correct Answer: D

Rationale: The statement "Things will look better tomorrow after a good night's sleep" falls under the nontherapeutic technique of giving false reassurance. This is because it offers comfort without any real basis for such a promise. It can minimize the client's feelings and concerns by implying that sleep alone will solve their problems. Providing false reassurance can hinder open communication, trust, and the client's ability to address their emotions and issues effectively. In therapeutic communication, it's important to acknowledge the client's feelings and offer support without providing guarantees that may not be true.