A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?
Inform the client about confidentiality rights.
Establish boundaries between the nurse and the client.
Set short- and long-term objectives for the future.
Evaluate progress toward predetermined goals.
The Correct Answer is D
A. Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B. Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C. Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D. During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jaundice is not a commonly reported adverse effect of citalopram. It is more commonly associated with liver dysfunction or other medications.
B. Urinary retention is not a commonly reported adverse effect of citalopram. It is more commonly associated with anticholinergic medications.
C. Bruising is not a commonly reported adverse effect of citalopram. It is more commonly associated with medications that affect platelet function or clotting factors.
D. Decreased libido (reduced sexual desire) is a potential adverse effect of citalopram, as it is with other selective serotonin reuptake inhibitors (SSRIs). Monitoring for changes in sexual function is important because it can affect quality of life and treatment adherence.
Correct Answer is C
Explanation
A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.
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