A staff nurse is working with a client who has been mute and very ...

[laurencescou]

A staff nurse is working with a client who has been mute and very withdrawn. When the client begins to verbalize, it is obvious that he has a thought disorder.
 
  After 4 weeks, the client suddenly encroaches on the nurse's personal space by touching her breast. The most therapeutic response by the nurse would be to:
  1. Ignore this since the client is, at last, responding
  2. Firmly communicate acceptable boundaries to the client
  3. Gently touch the client's head and observe his reaction
  4. Smile at the client and tell him you don't like to be touched

Question 2

The nurse and client are in the orientation stage of the nurse-client relationship. Of the following, which strategy should be part of the plan for care?
 
  1. Giving advice
  2. Giving reassurance
  3. Giving information
  4. Giving approval

[jennafosdick]

Answer to Question 1

ANS: 2
The most therapeutic response is to clearly communicate appropriate boundaries. There are times when clients misinterpret the nurse's nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. 1. This would allow the be-havior to be repeated with others, perhaps with disastrous results. 3. Touch is often misinterpret-ed by psychotic clients. 4. This communication is incongruent.

Answer to Question 2

ANS: 3
The nurse is often called upon to give information in the orientation phase of the nurse-client re-lationship (e.g., establishing parameters of the relationship, establishing a contract). The other op-tions are nontherapeutic techniques.