Nokea
The nurse working on the mental health unit is in the orientation (introductory) phase of the therapeutic nurse-client relationship. Which intervention is representative of this phase of the relationship?
- A. The nurse and client determine the contract for time.
- B. The client is encouraged to make use of all services depending on need.
- C. The client begins to identify with the nurse, and trust and rapport are maintained.
- D. The nurse focuses on facilitating the therapeutic expression of the client's feelings.
Correct Answer: A
Rationale: In the orientation (introductory phase) of the therapeutic nurse-client relationship, the client and nurse meet and determine the contract for time, such as how often to meet, the length of the meetings, and when termination is anticipated to occur. Utilizing services, identification with the nurse, and expression of feelings are appropriate for the working phase of the therapeutic nurse-client relationship.
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While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client's degree of adjustment to the new diagnosis?
- A. Is there anyone to help with housework and shopping?'
- B. How do you feel about making changes to your lifestyle?'
- C. Do you understand the schedule for your new medications?'
- D. Did you make a follow-up appointment with your provider?'
Correct Answer: B
Rationale: Exploring feelings assists the nurse with determining the individualized plan of care for the client who is adjusting to a new diagnosis. The correct option is the best question to ask the client because it is likely to elicit the most revealing information about the client's feelings about CAD and the requisite lifestyle changes that can help maintain health and wellness. The remaining choices are aspects of post-hospital care, but they are unlikely to uncover as much information about the client's adjustment to CAD because they are closed-ended questions.
The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority?
- A. Directing the discussions so that teaching needs are met
- B. Focusing directly on the client's message regarding needs
- C. Reflecting only facts related to the client's expressed concerns
- D. Reacting to the client's responses in a matter-of-fact, professional manner
Correct Answer: B
Rationale: For effective communication, the nurse uses active listening and assesses for verbal and nonverbal communication to receive the client's intended message, thus creating an environment in which the client feels comfortable expressing feelings. An authoritarian approach is directive and not permissive, and it is unlikely to create an environment for the free exchange of thoughts and ideas. Reflecting facts only is a barrier to effective communication because subjective information can also provide a stimulus for effective communication. Reacting in a matter-of-fact manner can be an ineffective strategy for facilitating communication.
The student nurse is listening to a lecture on caring for clients with thrombophlebitis. Which statement by the student nurse indicates that the teaching has been effective?
- A. Elevating the affected leg is indicated.'
- B. Keeping the affected leg flat encourages healing.'
- C. Engaging in activity as tolerated should be encouraged.'
- D. Maintaining bathroom privileges is the most important action.'
Correct Answer: A
Rationale: The nurse plans to elevate the affected extremity because this facilitates venous return by using gravity to improve blood return to the heart, decreases venous pressure, and helps relieve edema and pain. Option 2 does not facilitate venous return and thus is not indicated for a client with thrombophlebitis. Options 3 and 4 are unsuitable activities for a client on bed rest.
A client has been using crutches to ambulate for 1 week and now reports pain, fatigue, and frustration with crutch walking. How should the nurse respond when the client states, 'I feel like I will always be crippled'?
- A. Tell me what makes this so bothersome for you.'
- B. I know how you feel. I had to use crutches before too.'
- C. Why don't you take a couple of days off of work and rest?'
- D. Just remember, you'll be done with the crutches in another month.'
Correct Answer: A
Rationale: The correct option demonstrates the therapeutic communication technique of clarification and validation and indicates that the nurse is dealing with the client's problem from the client's perspective. Option 2 devalues the client's feelings and thus blocks communication. Option 3 gives advice and is a communication block. Option 4 provides false reassurances because the client may not be done with the crutches in another month. Additionally, it does not focus on the present problem.
The partner of a client who has an esophageal tube introduced for a second time tells the nurse, 'I thought having this tube down the nose the first time would convince anyone to quit drinking.' Which response to the statement should the nurse make?
- A. I think you are a good person to stay with her.'
- B. Alcoholism is a disease that affects the whole family.'
- C. Have you discussed this subject at the Al-Anon meetings?'
- D. You sound frustrated dealing with such a drinking problem.'
Correct Answer: D
Rationale: In option 4, the nurse uses the therapeutic communication techniques of clarifying and focusing to assist the client's partner with expressing feelings about the client's chronic illness. Showing approval, stereotyping, and changing the subject are nontherapeutic techniques that block communication.