A nurse on a mental health unit is preparing to assist with the admission of a new client. Which of the following actions should the nurse plan to take during the therapeutic nurse-client relationship? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)
Introduce self and set goals for the relationship.
Examine personal thoughts and feelings about meeting the client.
Summarize the achievement of goals that have been met.
Assist the client with identifying problem-solving techniques,
The Correct Answer is B,A,D,C
A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.
B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.
C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.
D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I will decrease my fluid intake to reduce incontinence.”: Reducing fluid intake can lead to concentrated urine and bladder irritation, which may worsen urinary urgency and incontinence. Adequate hydration is encouraged rather than fluid restriction for managing cystocele symptoms.
B. “I will experience less urinary incontinence if I use artificial sweeteners.”: Artificial sweeteners can irritate the bladder and increase urinary frequency or urgency. Their use may exacerbate urinary incontinence rather than improve symptoms.
C. “I will practice perineal exercises to decrease urinary leakage.”: Perineal (Kegel) exercises strengthen the pelvic floor muscles that support the bladder and urethra. Regular practice can improve muscle tone and reduce urinary leakage associated with a cystocele.
D. “I should use a perineal spray to reduce odor from urinary leakage.”: Perineal sprays may mask odor but do not address the underlying pelvic floor weakness. Some products can also irritate the perineal area, potentially worsening discomfort or skin breakdown.
Correct Answer is C
Explanation
A. Frequent urge to urinate: Urinary frequency and urgency are expected findings after TURP due to bladder and urethral irritation from surgery and catheterization. These sensations typically improve as inflammation subsides and do not require immediate provider notification.
B. Occasional small clots in the urine: Small clots can be expected during the early postoperative period following TURP as the prostatic tissue heals. Continuous bladder irrigation often helps flush these clots, and their presence alone does not indicate a complication unless they become large or obstruct urine flow.
C. Dark red urine: Dark red urine indicates active bleeding and is an abnormal finding 1 day post-TURP. This suggests possible hemorrhage or inadequate hemostasis and requires prompt provider notification to prevent complications such as clot retention or hypovolemia.
D. Urine output of 300 mL over 8 hr: This urine output averages approximately 37.5 mL/hr, which is within acceptable limits for an adult postoperative client. Adequate output suggests sufficient renal perfusion and does not require immediate intervention.
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