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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Correct Answer is D

Explanation

A. "Don't worry about it. Your anxiety will lessen once the massage begins."
This response dismisses the client's concerns and may not be respectful of their boundaries. It does not acknowledge the client's discomfort and does not offer a solution to address their preference.

B. "Why don't you like to be touched by others?"
While the nurse is attempting to understand the client's feelings, this question might come across as invasive or judgmental. The client may not feel comfortable discussing their reasons for not liking to be touched, and this response does not offer an immediate solution to the issue at hand.

C. "I will request that the massage therapist wear gloves during your treatment."
This response shows an attempt to accommodate the client's preference by suggesting a practical solution, such as wearing gloves to create a physical barrier. However, it's important to note that some individuals may still find this uncomfortable, and it might not be a universally effective solution for everyone.

D. "I will tell your provider that you would like a treatment other than massage."
This response acknowledges the client's discomfort and demonstrates respect for their boundaries. It indicates the nurse's intention to advocate for the client's preferences and well-being. By informing the provider about the client's aversion to touch, the nurse opens the door to exploring alternative treatment options that are more suitable for the client's comfort level.

A. Reassure staff members that the debriefing is confidential. B. Have staff members discuss their involvement in the event. C. Ask staff members to describe their most traumatic memories of the event. D. Provide stress-management exercises to the staff members.

Correct Answer is A

Explanation

A. "Reassure staff members that the debriefing is confidential."
This is an appropriate first step. Ensuring confidentiality creates a safe environment where individuals feel comfortable sharing their experiences and emotions.

B. "Have staff members discuss their involvement in the event."
This can be a part of the debriefing process, but it might not be the first step. Generally, individuals are given the option to share their experiences, but they should not be forced to do so. Some might not be ready to talk about their involvement immediately.

C. "Ask staff members to describe their most traumatic memories of the event."
This might be too intrusive as a first step. It's important to approach discussions about specific traumatic memories with caution and only when individuals are comfortable sharing.

D. "Provide stress-management exercises to the staff members."
This could be a helpful step after ensuring confidentiality and allowing individuals the opportunity to express their feelings. Stress-management exercises can provide valuable coping strategies.

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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?

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