A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Summarize the objectives the client achieved during the relationship.

Present issues regarding confidentiality.

Promote the client's problem-solving skills.

identify the responsibilities of the client and nurse.

Answer and Explanation

The Correct Answer is C

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

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Correct Answer is A

Explanation

A. Initiates social interactions with caregivers:One of the key goals for adolescents with autism spectrum disorder (ASD) is to improve social skills and interactions. Encouraging the adolescent to initiate social interactions is a positive and realistic outcome that promotes social development and enhances communication skills.

B. Meets own needs without manipulating others:While fostering independence and self-advocacy is important, adolescents with ASD may struggle with understanding social cues and may not manipulate others in a typical sense. This outcome may not be as relevant or achievable for the individual with ASD.

C. Changes behavior as a result of peer pressure:Adolescents with ASD may have difficulty understanding and responding to peer pressure in the same way as their neurotypical peers. This outcome may not be appropriate or realistic for someone with ASD, as it can lead to increased anxiety or discomfort.

D. Acknowledges that his delusions are not real:This outcome is more relevant to conditions such as schizophrenia or severe psychotic disorders, rather than ASD. Adolescents with autism may experience different cognitive challenges but generally do not have delusions in the way that individuals with psychotic disorders do.

A. "Do you feel you need treatment?" B. "Who is the governor of this state?" C. "What do you get when you subtract 7 from 100?" D. "How do you get money for your needs?"

Correct Answer is A

Explanation

A. "Do you feel you need treatment?"
Asking the client, "Do you feel you need treatment?" assesses their insight into their own mental health condition. Insight refers to the client's awareness and understanding of their illness, including recognizing the need for treatment. A positive response to this question indicates the client's awareness of their condition and willingness to seek help, demonstrating good insight.

B. "Who is the governor of this state?"
This question assesses the client's orientation to time, place, and current events. It is useful for assessing cognitive functioning but does not specifically measure insight into one's own mental health.

C. "What do you get when you subtract 7 from 100?"
This question assesses the client's cognitive functioning, specifically mathematical abilities. It is useful for evaluating cognitive skills but does not address insight into mental health.

D. "How do you get money for your needs?"
This question assesses the client's problem-solving abilities and understanding of practical matters. It is relevant for assessing functional abilities but does not specifically measure insight into their mental health condition.

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A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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