During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)
Reviewing diagnostic test results.
Interviewing the client and significant others.
Performing a physical assessment.
Interpreting the behaviors of the client.
Correct Answer : A,B,C,D
Choice A rationale
Reviewing diagnostic test results is a crucial method for gathering data during the assessment phase of the nursing process. These results can provide valuable insights into the client’s health status and help to guide the planning and implementation of care.
Choice B rationale
Interviewing the client and significant others is another important method for data collection. This can help to gather information about the client’s symptoms, lifestyle, and personal history, which can all inform the care provided.
Choice C rationale
Performing a physical assessment is a key part of data collection in the nursing process. This involves examining the client’s physical condition and looking for any signs of illness or injury.
Choice D rationale
Interpreting the behaviors of the client is also a crucial part of data collection. This can provide insights into the client’s mental and emotional state, which can be particularly important in mental health nursing.
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Correct Answer is C
Explanation
Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. The main focus is on the client’s needs and concerns.
Choice B rationale
Focusing on the attitude of the client is not the primary goal of therapeutic communication. The main goal is to understand the client’s experiences and feelings.
Choice C rationale
The primary goals of therapeutic communication are to focus on the client and to build a rapport. This involves understanding the client’s needs, concerns, and emotions effectively.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The main focus should be on the client.
Correct Answer is A
Explanation
Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.
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