The nurse is considering the need for both effective means of communication and safety when caring for a patient with impulse control issues and poor social skills. Which nursing intervention is most appropriate to address these needs?
a. Reminding the patient with each interaction what space boundaries are consid-ered safe and desired
b. Asking the patient to describe and set space boundaries that feel safe and facili-tate effective communication
c. Clearly setting space boundaries for the patient so both patient and staff feel safe and can communicate more effectively
d. Discussing the need for space boundaries and how they help both the patient and the staff feel safe and aide in communicating effectively
ANS: D
Space as a concept of boundaries and safety is important to understand because the nurse and the patient need to respect the distance that each needs. For successful communication to occur, both parties need to feel safe. Some patients have problems with their boundaries and invade other patients' own safe zones; patients who perceive this as threatening react aggres-sively to such boundary violations. The nurse may need to help the patient understand the need for appropriate distances in order for everyone to feel safe and to communicate effec-tively. Reminding the patient of what the boundaries are without first discussing the im-portance of space boundaries is not an effective technique. Having the patient set the bound-aries does not take into consideration the needs of others, whereas staff setting the bounda-ries without patient involvement ignores the needs of the patient and prevents the patient from understanding of the situation.
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