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,

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Increased appetite: Radiation therapy often causes anorexia, nausea, and taste changes, leading to decreased appetite rather than an increase. Appetite suppression is a common side effect in clients receiving treatment for head and neck cancers.

B. Loose stools: Loose stools are not a typical side effect of external radiation to the throat. Gastrointestinal effects are more likely with abdominal or pelvic radiation.

C. Loss of taste: Radiation to the head and neck commonly affects the taste buds and salivary glands, resulting in dysgeusia or partial/complete loss of taste. This is an expected manifestation and can affect nutrition and quality of life.

D. Bladder infection: Radiation to the throat does not directly impact the urinary tract. Urinary tract infections are unrelated to external radiation for throat cancer unless there are other risk factors.

A. Determine the client's pattern for voiding B. Discourage intake of carbonated beverages. C. Offer toileting opportunities every 1 to 2 hr D. Assist the client with relation techniques.

Correct Answer is A

Explanation

A. Determine the client's pattern for voiding: Assessing the client’s typical voiding schedule provides essential baseline data to individualize the bladder training program. Understanding frequency, timing, and triggers allows the nurse to develop an effective and structured plan for toileting.

B. Discourage intake of carbonated beverages: Limiting bladder irritants can support continence but is secondary to first assessing the client’s voiding patterns. Dietary modifications alone will not optimize bladder training without an individualized schedule.

C. Offer toileting opportunities every 1 to 2 hr: Regular toileting supports bladder control, but it should be based on the client’s identified voiding pattern. Implementing a schedule before assessment may be inefficient or disruptive.

D. Assist the client with relaxation techniques: Relaxation can help facilitate voiding, but it is an adjunct intervention. Determining the voiding pattern first ensures that relaxation strategies are applied at appropriate times to maximize effectiveness.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

Correct Answer is A

Explanation

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