Nokea
During a regular home health visit to an elderly client, the nurse observes that the client has feelings of hopelessness and despair. The client says, 'I'm old, and my life has no purpose anymore. But promise me you won't tell anyone.' How should the nurse respond?
- A. Don't worry, I won't tell anyone else
- B. I'm sorry, but I can't keep that kind of secret
- C. Let's talk about something to cheer you up
- D. What can we do to help you feel better
Correct Answer: B
Rationale: Keeping secrets with a client is not permissible, especially when the client's safety is concerned.
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During the orientation phase of the nurse/patient relationship, the nurse directs the patient to do which of the following?
- A. Identify problems to examine
- B. Express needs and feelings
- C. Develop interpersonal skills
- D. Identify self-care strategies
Correct Answer: A
Rationale: The orientation phase focuses on identifying problems to examine.
Which is a standard for establishing a code of conduct for living?
- A. Acceptance
- B. Empathy
- C. Values
- D. Positive regard
Correct Answer: C
Rationale: Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living.
Which role of the nurse is most likely to create difficulty for the nurse/client relationship if the client confuses physical care with intimacy and sexual interest?
- A. Teacher
- B. Caregiver
- C. Advocate
- D. Parent surrogate
Correct Answer: B
Rationale: Physical care in the caregiver role can be confused with intimacy, potentially eroding the therapeutic relationship.
Which of the following behaviors by the nurse demonstrate positive regard? Select all that apply.
- A. Communicating judgments about the client's behavior
- B. Calling the client by name
- C. Spending time with the client
- D. Responding openly
- E. Considering the client's ideas and preference when planning care
Correct Answer: B,C,D,E
Rationale: Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client. The nurse also conveys positive regard by considering the client's ideas and preferences when planning care. The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior.
A nurse is using the Johari window to identify the degree to which he feels comfortable communicating with others. After completing the exercise, the nurse discovers that quadrant 1 has the longest list of qualities. This indicates which of the following about the nurse?
- A. The nurse conceals personal information about himself.
- B. The nurse needs to increase insight into his own characteristics.
- C. The nurse is open to others.
- D. The patient is sharing more than the nurse in the therapeutic relationship.
Correct Answer: C
Rationale: When using the Johari window, if quadrant 1 is the largest, this indicates that the nurse is open to others.