A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Determine previous coping skills used by the client.

Facilitate the client's problem-solving skillls

Assist the client in expressing alternative behaviours.

Establish the responsibilities of the nurse and client

Answer and Explanation

The Correct Answer is D

Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Recommended: Alternating between solids and liquids can help manage nausea and vomiting. It ensures that the stomach isn't overloaded and can help in maintaining hydration and nutritional intake. Drinking liquids between meals rather than with meals can prevent over-distension of the stomach, which may reduce nausea.

B. Recommended:Eating small, frequent meals helps keep the stomach from becoming too full or too empty, which can both trigger nausea. This practice ensures a steady supply of nutrients and calories, which is especially important during pregnancy.

C. Recommended:Ginger has properties that can help soothe nausea. Warm liquids are generally more tolerated than cold liquids.

D.High-fat foods are more difficult to digest and can slow gastric emptying, which may worsen nausea and vomiting. They can also increase the risk of acid reflux, which is common during pregnancy and can exacerbate nausea.

Recommended is correct. The nurse should indicate which actions are recommended for the client.

A. Request a PRN restraint prescription for clients who are aggressive. B. Remove the client's restraint every 4 hr. C. Attach the restraint to the bed's side rails. D. Document the client’s condition after every 15 minutes

Correct Answer is D

Explanation

A.PRN (as needed) restraint prescriptions are not appropriate because restraints should only be used in situations where there is an immediate need for safety and all other methods of de-escalation have failed. Restraint use must be based on a current assessment of the client's behavior, and a specific prescription should be obtained each time restraints are applied.

B.Restraints should be removed every 2 hours to assess the client's skin, circulation, and range of motion, and to provide an opportunity for toileting, hydration, and movement. Prolonged use without breaks increases the risk of complications such as skin breakdown or impaired circulation.

C.Attach the restraint to the bed's side rails. Restraints should not be attached to the bed's side rails because it can lead to serious injuries if the client attempts to climb over the side rails while restrained. Instead, restraints should be attached to specific restraint ties or straps that are part of the bed frame.

D.The client's condition, including circulation, skin integrity, and behavior, should be monitored and documented every 15 minutes while restraints are in use. This frequent assessment helps ensure the client’s safety and comfort, and allows for early identification of potential complications.

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A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E"]

Explanation

A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

Correct Answer is D

Explanation

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