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Question

Difficulty: MediumBehavioral Interventions

A nurse provides care for a client hospitalized with a severe respiratory infection. During the shift, the client repeatedly activates the call bell for minor demands, attempts to touch the nurse's arm, and makes sexually explicit remarks regarding the nurse's appearance. Which of the following is the priority behavioral intervention for the nurse to implement?

  1. Directly inform the client that the comments are unacceptable and clearly define the professional boundaries of the nurse-client relationship.Answer
  2. B
    Ask the client to explain the reasoning behind their need to make sexually explicit statements.
  3. C
    Reassign the client's routine vital signs and hygiene care to unlicensed assistive personnel to reduce further conflict.
  4. D
    Contact the prescribing provider to request an as-needed antianxiety medication to calm the client's disinhibited behavior.

Answer

The priority intervention is to directly inform the client that their comments are unacceptable and clearly establish professional boundaries.
The nurse must immediately set firm, clear limits on inappropriate behavior to establish professional boundaries and maintain a therapeutic environment. Direct communication without anger or judgment is the most effective initial behavioral intervention when a client exhibits boundary-testing or sexually explicit behavior.

Step-by-Step Solution

1
Assess the client's behavior and the immediate risk to staff.
The client is demonstrating inappropriate, boundary-testing behavior without physical violence.
Accurate assessment determines the appropriate level of intervention required.
2
Determine the least restrictive intervention to manage the behavior.
Verbal limit-setting is identified as the first-line, least restrictive approach.
Nursing care must always escalate from the least restrictive to the most restrictive interventions.
3
Implement the behavioral intervention.
The nurse provides clear, direct feedback about unacceptable behavior and reinforces professional boundaries.
Clear boundaries stop the behavior, maintain a safe environment, and establish expectations for future interactions.

Key Concept

Behavioral Limit Setting and Professional Boundaries
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Topics

Behavioral Interventions

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