A nurse is preparing to meet with a client who was recently admitted to an outpatient mental health facility. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship?

identify the goals that the client achieved during the relationship.

Assist the client to make changes in her behavior.

Inform the client about confidentiality issues.

Discuss the client's responsibilities for the relationship

Answer and Explanation

The Correct Answer is B

A. Identify the goals that the client achieved during the relationship:
This activity typically occurs during the termination or closure phase of the nurse-client relationship. It involves reflecting on the progress made by the client toward their goals. During this phase, both the nurse and the client review the goals set at the beginning of the therapeutic relationship and identify which ones have been achieved. This helps in evaluating the effectiveness of the therapeutic interventions.

B. Assist the client to make changes in her behavior:
This action is a central aspect of the working phase. In this phase, the nurse and client collaboratively work on addressing the client's issues. The nurse provides support, guidance, and appropriate interventions to help the client modify their thoughts, emotions, and behaviors. The goal is to facilitate positive changes and promote the client's mental and emotional well-being.

C. Inform the client about confidentiality issues:
Discussing confidentiality is essential at the beginning of the therapeutic relationship, during the orientation phase. The nurse informs the client about the limits of confidentiality, explaining what information will be kept confidential and under what circumstances confidentiality might need to be breached (such as when there is a risk of harm to the client or others). This discussion helps establish trust and clear boundaries within the relationship.

D. Discuss the client's responsibilities for the relationship:
Clarifying the client's responsibilities occurs primarily during the orientation phase. In this phase, the nurse outlines what the client can expect from the therapeutic relationship and what is expected from them. This includes discussing the client's active participation in the process, their commitment to attending sessions, being open and honest, and actively engaging in therapeutic activities and homework assignments.

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Free Nursing Study Resources

Correct Answer is ["90"]

Explanation

To find out how many mL the nurse should administer for the total daily dose, we need to calculate the total daily dose and then convert it to mL using the available concentration.

The client is prescribed hydroxyzine 60 mg PO every 8 hours. To find the total daily dose, we can first calculate the dose per day and then convert it to mL.

Dose per day = Dose per dose interval x Number of doses per day

Dose per day = 60 mg x 3 (every 8 hours)

Dose per day = 180 mg per day

Now, we need to convert this dose to mL using the available concentration:

Concentration: 10 mg/5 mL

To find out how many mL for 180 mg, we can set up a proportion:

(10 mg / 5 mL) = (180 mg / x mL)

Cross-multiply:

10 mg * x mL = 5 mL * 180 mg

Now, solve for x (the number of mL):

x mL = (5 mL * 180 mg) / 10 mg

x mL = 900 mL / 10 mg

x mL = 90 mL

So, the nurse should administer 90 mL for the total daily dose.

A. Assess the need for physical restraints. B. Discuss the purpose of the medication with the client. C. Stop the newly licensed nurse from administering the medication. D. Demonstrate how to verbally de-escalate the situation.

Correct Answer is D

Explanation

A. Assess the need for physical restraints:
Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.

B. Discuss the purpose of the medication with the client:
Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.

C. Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.

D. Demonstrate how to verbally de-escalate the situation:
This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.

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A nurse is preparing to meet with a client who was recently admitted to an outpatient mental health facility. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["90"]

Explanation

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Correct Answer is D

Explanation

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