A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship.
Which of the following statements should the nurse make during this phase?
"We should establish our roles in the initial session."
"Let me show you simple relaxation exercises to manage stress."
"Let's talk about how you can change your response to stress."
"We should discuss resources to implement in your daily life." .
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 140/min is not a specific indicator of desmopressin effectiveness in a child with diabetes insipidus. The effectiveness of desmopressin is primarily evaluated based on the reduction in excessive urination and thirst associated with the condition. Monitoring heart rate is essential in certain situations but is not a direct measure of desmopressin efficacy in managing diabetes insipidus.
Choice B rationale:
Cessation of nocturnal enuresis (bedwetting) is a significant indication that desmopressin, an antidiuretic hormone, is effective. One of the main symptoms of diabetes insipidus is excessive urination, including during the night, leading to bedwetting. When desmopressin effectively reduces urine production, patients often experience improvement in these symptoms, including the cessation of nocturnal enuresis.
Choice C rationale:
Capillary refill of 3 seconds is a measurement used to assess peripheral perfusion and circulatory status. While it is essential to monitor capillary refill in pediatric patients, especially in cases of dehydration or circulatory compromise, it is not a specific indicator of desmopressin effectiveness in managing diabetes insipidus. Capillary refill time is more relevant in the assessment of cardiovascular function and fluid status.
Choice D rationale:
The absence of hypoglycemic episodes is not a direct indicator of desmopressin effectiveness. Diabetes insipidus is unrelated to blood glucose levels, as it involves the dysregulation of water balance due to insufficient antidiuretic hormone. While it is essential to monitor blood glucose levels in patients with diabetes mellitus, it is not relevant to assessing the effectiveness of desmopressin in treating diabetes insipidus.
Correct Answer is A
Explanation
Answer is: a. "The estimated blood loss was 250 milliliters."
Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.
Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.
Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.
Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.
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