A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should
the nurse help the client develop problem-solving skills?
Preinteraction phase
Working phase
Orientation phase
Termination phase
The Correct Answer is B
The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.
The other options are not correct because:
a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.
c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).
d) The termination phase is the final stage of the nurse-client relationship.
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Correct Answer is C
Explanation
c. Weak cry
Explanation: In the context of a newborn with shoulder dystocia, a weak cry can be an indication of pain. Newborns communicate their discomfort or pain through crying, and a weak cry may suggest that the newborn is experiencing pain or distress.
Option a, lip-smacking, is not necessarily a specific indication of pain in this situation. Lip-smacking can
occur due to various reasons and may not solely indicate pain.
Option b, a stiff posture, may be more indicative of muscle tension or rigidity rather than pain in this
scenario.
Option d, tongue-darting, is not a specific indicator of pain in this context. Tongue-darting is a common behavior in newborns and may not be directly related to pain.
By recognizing a weak cry as a potential indication of pain in the newborn with shoulder dystocia, the nurse
can provide appropriate interventions and support to manage the newborn's pain and discomfort.
Correct Answer is B
Explanation
b. Keep suction equipment at the client's bedside.
The nurse should plan to include keeping suction equipment at the client's bedside as an intervention for a client with Parkinson's disease. Parkinson's disease can cause dysphagia (difficulty swallowing) and an increased risk of aspiration. Having suction equipment readily available allows for prompt intervention in case of choking or aspiration episodes, ensuring the client's safety.
Explanation for the other options:
a. Restrict the client's fluid intake: Restricting the client's fluid intake is not typically indicated in the care of a client with Parkinson's disease. Adequate hydration is important for overall health and well-being. However, specific fluid restrictions may be necessary in certain situations, such as if the client has coexisting conditions like heart failure or kidney disease, which should be assessed and determined by the healthcare provider.
c. Instruct the client to look down when ambulating: In Parkinson's disease, individuals often experience a forward-flexed posture and a shuffling gait. Instructing the client to look down when ambulating is not an appropriate intervention. Instead, the nurse should encourage the client to maintain an upright posture, take smaller steps, and focus on taking deliberate and controlled movements to promote stability and reduce the risk of falls.
d. Position the client supine after eating: Positioning the client supine after eating is not recommended for a client with Parkinson's disease. This position can increase the risk of aspiration, as it may promote reflux and regurgitation of stomach contents. Instead, the nurse should advise the client to maintain an upright position, such as sitting in a chair or using a recliner with appropriate head support, to aid digestion and reduce the risk of aspiration.
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