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 A
Explanation
A. The client has a sudden increase in energy: A sudden increase in energy in a client with major depressive disorder can indicate an elevated risk for suicidal behavior, especially if the client previously had low motivation or lethargy. This change is an urgent safety concern and should be reported immediately.
B. The client reports a change in sleeping patterns: Changes in sleep are common in depression and with antidepressant therapy. While important to monitor, they are not as immediately life-threatening as sudden energy changes that could precede suicidal actions.
C. The client is withdrawn and uncommunicative: Social withdrawal is a common symptom of depression. While concerning, it does not require the same urgent response as a sudden increase in energy that could indicate imminent risk.
D. The client neglects personal hygiene: Poor self-care is typical in depression and should be addressed in ongoing care, but it does not present the same immediate risk as potential suicidal behavior.
Correct Answer is C
Explanation
A. Peeling of the hands and feet: Desquamation of the hands and feet is commonly associated with conditions such as Kawasaki disease or scarlet fever during the healing phase. It is not a typical manifestation of pertussis.
B. Koplik spots: Koplik spots are small white lesions on the buccal mucosa that are characteristic of measles. They are not seen in pertussis and point toward a different viral illness.
C. Paroxysmal cough: Pertussis is characterized by severe, repetitive coughing spells that occur in rapid succession. These paroxysmal coughs may be followed by a high-pitched inspiratory “whoop” and can lead to vomiting or exhaustion.
D. Beefy, red tongue: A beefy red tongue is commonly associated with scarlet fever or other streptococcal infections. It is not a defining feature of pertussis.
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