A client has a reddened area on his right heel.
What is the best intervention by the nurse to prevent further skin and tissue breakdown?

Working.

The working phase of the therapeutic relationship is when the nurse and client work together to develop and implement strategies to achieve the client’s goals.

In this case, the goal is to reduce weight, so the nurse and client are working on strategies to achieve that goal.

Choice A is not an answer because the pre-interaction phase occurs before the nurse and client meet and involves the nurse preparing for the first interaction with the client.

Choice B is not an answer because the orientation phase is when the nurse and client get to know each other and establish trust and rapport.

Choice D is not an answer because the termination phase occurs when the therapeutic relationship ends and involves evaluating progress and planning for future care.

The priority responsibility of the nurse is to call for a Cambodian interpreter.

This ensures that the mother’s needs and concerns are accurately communicated and understood.

It also helps to prevent any misunderstandings or miscommunications that could occur if the daughter were to interpret.

Choice A is not an appropriate response because calling the chaplain for support may not address the language barrier.

Choice B is not an appropriate response because allowing unlicensed assistive personnel to interpret could result in inaccurate or incomplete information being conveyed.

Choice D is not an appropriate response because continuing to work with the daughter for interpretation could result in misunderstandings or miscommunications.