A staff nurse is working with a client who has been mute and very withdrawn.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