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 B

Explanation

A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.

B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.

C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.

D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.

A. Determine the client's degree of physical dependence. B. Discuss the treatment plan with the client. C. Document the client's alcohol use in the medical record. D. Initiate a referral for treatment for alcohol use disorder.

Correct Answer is C

Explanation

A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.

B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.

C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.

D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.

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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

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