The nurse has established a therapeutic relationship with a client. Which behaviors identified will indicate that the client has entered into the identification phase of the nurse-client relationship?
The client is sharing feelings and emotions with the nurse.
The client is attending all therapy sessions and utilizing the services provided.
The client states that they feel the issues have been resolved and no longer need to come.
The client is answering questions related to the plan of care.
The Correct Answer is A
The identification phase of the nurse-client relationship is characterized by the client feeling comfortable and secure enough to open up and share their feelings, emotions, and personal experiences with the nurse. It involves establishing trust and rapport, which allows the client to feel supported and understood by the nurse. Sharing feelings and emotions indicates that the client has reached a level of comfort and trust in the therapeutic relationship, making it a key indicator of the identification phase.
The other behaviors mentioned in the options are not specifically related to the identification phase:
● The client attending therapy sessions and utilizing services provided is an important aspect of engagement and active participation in the therapeutic process. However, it does not specifically indicate the identification phase of the relationship.
● The client stating that they feel the issues have been resolved and no longer need to come suggests the termination phase of the nurse-client relationship rather than the identification phase. The termination phase occurs when the client feels they have achieved their goals and no longer require ongoing therapy.
● The client answering questions related to the plan of care is a general indicator of communication and collaboration in the therapeutic process. It does not specifically signify the identification phase but rather active involvement in the treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The purpose of asking the client to describe their problems during the assessment is to obtain information about their perception of the problem. By asking the client to describe their problems
in their own words, the nurse gains insight into how the client perceives and understands their current situation. This information helps the nurse to understand the client's subjective experience, their concerns, and their specific needs related to the problem. It allows for a more accurate assessment of the client's situation and helps in developing an individualized plan of care tailored to their unique needs.
● Personal needs: While understanding a client’s personal needs is important in providing care, it is not the primary purpose of this specific question. The nurse may ask other questions to gather information about the client’s personal needs.
● Communication skills: Assessing a client’s communication skills may be important in some cases, but it is not the primary purpose of this specific question. The nurse may use other methods to assess the client’s communication skills.
● Admitting diagnosis: The admitting diagnosis is typically determined by a physician and is based on medical tests and examinations. While the nurse may gather information that can contribute to determining the admitting diagnosis, it is not the primary purpose of this specific question.
Correct Answer is C
Explanation
During a panic attack, the client may experience intense fear and anxiety, accompanied by physical symptoms such as rapid heart rate, shortness of breath, and trembling. The most critical action the nurse should take is to stay with the client and provide support. By remaining present, the nurse can help the client feel safe and reassured, while also monitoring their condition for any signs of worsening distress or the need for further intervention. Maintaining a safe environment is also crucial to prevent any harm to the client or others. Once the immediate crisis is managed and the client starts to calm down, the nurse can then proceed with other interventions, such as education on coping strategies or engaging in activities to redirect their focus. However, in this situation, the priority is to provide immediate support and ensure the client's safety.
The following are incorrect because:
Educate the client in ways to prevent a future panic attack: While education on preventing future panic attacks is important, it is not the priority action during an ongoing panic attack. The client is currently in distress and needs immediate support and assistance in managing the panic attack. Education can be provided at a later time when the client is calmer and more receptive to learning.
Take the client for a walk around the unit: Taking the client for a walk may be a beneficial intervention to help reduce anxiety and promote relaxation in some situations. However, during an active panic attack, the client may be experiencing significant distress and physical symptoms that can make movement difficult or exacerbate their symptoms. It is essential to prioritize the client's immediate needs and provide a supportive environment before considering other activities or interventions.
Redirect the client to an activity or task: Redirecting the client to an activity or task may be helpful in some situations to distract them from their anxiety. However, during a panic attack, the client may find it challenging to engage in activities or focus on tasks due to their heightened state of anxiety. Redirecting their attention without addressing their immediate distress may not be as effective or appropriate as providing support and maintaining a safe environment.
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