A nurse has for the past 4 weeks been working with a psychotic patient who has been mute and very withdrawn. The patient suddenly encroaches on the nurse's personal space by touching inappropriately
What is the most therapeutic response by the nurse to address this behavior?
a. Ignore it this time because the patient is, at last, responding.
b. Firmly communicate acceptable boundaries to the patient.
c. Gently touch the patient's head and then observe the reaction.
d. Smile while telling the patient that people don't like being touched like that.
ANS: B
The therapeutic response is to clearly communicate appropriate boundaries. There are times when patients misinterpret the nurse's nurturing as an invitation to an intimate relationship. In these instances, boundaries must be firmly, but neutrally, explained. The behavior should not be ignored since doing so may well result in the patient repeating the behavior with others, perhaps with disastrous results. Touch is often misinterpreted by psychotic patients and in this case has no therapeutic value. Nonverbal communication should always be congruent so as to avoid confusing the patient.
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