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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Nurses should focus on clients' cultures, rather than their ethnicity, when providing care: Cultural competence involves understanding and respecting the beliefs, values, practices, and customs of different cultures. It is important for nurses to recognize that culture extends beyond ethnicity and encompasses various aspects such as religion, language, socioeconomic status, and more. By focusing on clients' cultures, nurses can provide care that is sensitive and tailored to their unique needs and preferences.

The following are incorrect:

Nonverbal communication is important in many cultures: Nonverbal communication, including body language, facial expressions, and gestures, plays a significant role in communication across cultures. Different cultures may have specific nonverbal cues and interpretations. Nurses

should be aware of these variations and understand how nonverbal communication impacts their interactions with clients. By being attentive to nonverbal cues, nurses can enhance communication, build trust, and promote effective care.

Nurses should not expect clients to adapt to the care provided regardless of culture: Culturally competent care acknowledges and respects the diversity of clients' cultural backgrounds. It is important for nurses to recognize that clients' cultural beliefs, values, and practices may influence their healthcare preferences and decisions. Nurses should strive to provide care that is congruent with clients' cultural values and preferences, rather than expecting them to adapt entirely to a standardized approach. This promotes patient-centered care and enhances client satisfaction and outcomes.

"Culture plays no role in determining when a client will seek medical care" is incorrect. Culture significantly influences an individual's healthcare-seeking behaviors, including beliefs about illness, preventive care practices, and help-seeking patterns. Understanding these cultural factors is essential for nurses to provide appropriate and effective care.

A. Temporary detaining orders for clients. B. The revolving door for clients. C. Decision to practice boarding. D. The cost of holding clients in the ED for over 48 hours.

Correct Answer is C

Explanation

Boarding refers to the practice of holding patients, including those with mental health disorders, in the emergency department (ED) for extended periods due to the unavailability of appropriate psychiatric or mental health treatment facilities. This situation often occurs when there is a lack of inpatient psychiatric beds or insufficient community-based mental health resources.

When the nurse notifies the manager about clients with mental health disorders still present in the ED for over 48 hours, they are likely raising concerns about the practice of boarding. The nurse is highlighting the issue of keeping individuals with mental health disorders in an inappropriate setting for an extended duration, which can have negative implications for both the clients and the ED.

The other options are not directly related to the phenomenon of clients with mental health disorders staying in the ED for an extended period:

1. Temporary detaining orders for clients: Temporary detaining orders refer to legal provisions that allow for the involuntary detention of individuals who are at risk to themselves or others due to mental health concerns. While this may be relevant in certain situations, it does not address the broader issue of clients staying in the ED beyond 48 hours.

2. The revolving door for clients: The revolving door phenomenon refers to individuals repeatedly seeking care in the ED due to ongoing or recurrent health issues. While this may be a concern in the context of mental health, it does not specifically address the issue of clients with mental health disorders staying in the ED for over 48 hours.

3. The cost of holding clients in the ED for over 48 hours: While the cost of providing care and resources to clients staying in the ED for an extended period is a valid consideration, it does not encompass the broader issue of the appropriateness of this practice for clients with mental health disorders.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

Correct Answer is B

Explanation

The nurse working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?

Correct Answer is C

Explanation

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