Personality and Mood Disorders Q 66
The nurse asks a client to roll up his sleeves so she can take his blood pressure. The client replies “If you want I can go naked for you.” The most therapeutic response by the nurse is:
A. “You’re attractive, but I’m not interested.”
B. “You wouldn’t be the first that I will see naked.”
C. “I will report you to the guard if you don’t control yourself.”
D. “I only need access to your arm. Putting up your sleeve is fine.”
Correct Answer: D. “I only need access to your arm. Putting up your sleeve is fine.”
The nurse needs to deal with the client with sexually connotative behavior in a casual, matter of fact way. Stay calm and be patient. Gently but firmly tell the person that the behavior is inappropriate.
Option A: Maintain consistent, firm boundaries. Don’t accidentally encourage inappropriate behavior by sending mixed signals, like briefly allowing the behavior one time and then reacting negatively the next time. Be consistently firm every time, saying “No, stop. I don’t like that.” or “Stop, that’s not right.”
Option B: These responses are not therapeutic because they are challenging and rejecting. Distract them and redirect to a positive activity. To distract, ask a question, turn on the TV, or offer a snack. To redirect, turn on some music they like, go for a walk, bring out their favorite hobby.
Option C: Threatening the client is not therapeutic. Recommendations for such interventions include redirection, same-sex caregivers, clothing that closes or fastens in the back, and patient and caregiver counseling and education. Most often the limiting factor of effectiveness in employing these strategies is the degree of the patient’s cognitive impairment.