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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.
B. This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.
C. This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.
D. This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.
Correct Answer is A
Explanation
- Seizure precautions are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness. Seizure precautions include providing a safe environment, monitoring the client's vital signs and neurological status, administering anticonvulsant medications, and documenting the onset, duration, and characteristics of any seizure activity.
- One of the potential complications of a seizure is aspiration, which is the inhalation of foreign material into the lungs, such as saliva, vomit, or food. Aspiration can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiration, the practical nurse (PN) should ensure the ready availability of equipment to perform suctioning of the trachea, which is the tube that connects the mouth and nose to the lungs. Suctioning of the trachea involves inserting a catheter through the nose or mouth into the trachea and applying negative pressure to remove any secretions or debris from the airway.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because inserting a urinary catheter is not related to seizure precautions or aspiration prevention.
Option C is incorrect because applying soft restraints may not be necessary or appropriate for a client who requires seizure precautions, as they may interfere with the natural movements of the seizure or cause injury to the client.
Option D is incorrect because inserting a nasogastric tube is not related to seizure precautions or aspiration prevention.
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