A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Wait for the client to initiate interactions with the nurse.

Set aside short, frequent times each day to spend with the client.

Disclose some personal information to the client.

Tell the client he reminds the nurse of her father.

Answer and Explanation

The Correct Answer is B

Building trust and rapport with a suspicious client takes time and consistency. By setting aside short, frequent times each day to spend with the client, the nurse demonstrates reliability, availability, and a commitment to the client's well-being. This approach allows the client to gradually develop trust and feel more comfortable interacting with the nurse.

The other options are not appropriate actions:

A. Waiting for the client to initiate interactions with the nurse may result in limited or no engagement, as the client's suspicion may hinder their willingness to reach out. It is important for the nurse to take an active role in building the therapeutic relationship.

C. Disclosing personal information to the client is not recommended. The nurse should maintain professional boundaries and focus on the client's needs and concerns rather than sharing personal details that may compromise the therapeutic relationship or create an imbalance of power.

D. Telling the client that he reminds the nurse of her father may inadvertently trigger the client's suspicious thoughts and reinforce their mistrust. Making such personal comparisons is not appropriate and can hinder the establishment of a therapeutic relationship. It is important to focus on the client's individual experiences and needs rather than making personal connections.

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Correct Answer is A

Explanation

The response "It sounds like you're having a difficult time" acknowledges the client's distress and validates their experience. It demonstrates empathy and shows the nurse's willingness to listen and provide support. This response encourages the client to express their feelings and concerns further, facilitating open communication and a therapeutic relationship.

The response "Why do you think you are so anxious?" may come across as confrontational or intrusive. It puts the client on the spot and may make them feel defensive or uncomfortable. It is important to create a supportive environment where the client feels safe to share their experiences without judgment.

The response "Everyone has trouble sleeping at times" minimizes the client's concerns and may invalidate their feelings. It does not address the client's anxiety or offer any support or guidance.

The response "Have you talked to your provider about this yet?" is a helpful question to explore whether the client has sought professional help. However, it should be used after acknowledging the client's difficulties and showing empathy. It can be part of a conversation about accessing appropriate care and resources.

A. Obtain client's weight weekly. B. Offer the client finger foods for meals. C. Speak loudly when addressing the client. D. Give long task at a time to the client E. Turn the clients TV on at night when they are unable to sleep. F. Encourage the client to take deep breaths when feeling agitated. G. Assess client's memory every shift.

Correct Answer is ["A","B","F","G"]

Explanation

From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
● Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
● Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
● Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
● Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:

● Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
● Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.

● Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.

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A nurse is caring for a newly admitted client who is suspicious of the nursing staff and other clients. Which of the following actions should the nurse take to establish a relationship with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","B","F","G"]

Explanation

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