The nurse is performing an admission assessment for a client on the behavioral health unit with depression and anxiety. Which goal of therapeutic communication will the nurse prioritize?
Implement interventions designed to address the client’s needs
Teach the client necessary self-care skills
Facilitate the client’s expression of emotions
Establish a therapeutic nurse-client relationship
The Correct Answer is D
Choice A reason: Implementing interventions addresses specific needs but is not the primary goal of therapeutic communication during admission. Interventions follow after building trust, as depression and anxiety require a strong therapeutic alliance to ensure effective treatment engagement, making this a secondary priority at this stage.
Choice B reason: Teaching self-care skills is important for long-term management but not the initial communication goal. Clients with depression and anxiety need trust and emotional safety first to engage in learning, making skill-building secondary to establishing a therapeutic relationship during the admission assessment.
Choice C reason: Facilitating emotional expression is a key component of therapeutic communication but depends on a trusting relationship. Without a strong nurse-client bond, clients with depression and anxiety may resist sharing emotions, making this goal important but secondary to establishing rapport during the initial assessment.
Choice D reason: Establishing a therapeutic nurse-client relationship is the priority during admission, as it builds trust and safety, critical for clients with depression and anxiety. This foundation enables emotional expression, engagement in interventions, and skill-building, ensuring effective communication and treatment adherence, making it the primary goal in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.
Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.
Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.
Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.
Correct Answer is ["2.5"]
Explanation
Step 1 is identify the total dose ordered
10 mg
Step 2 is identify the concentration available
4 mg per mL
Step 3 is divide the ordered dose by the concentration per mL
(10 ÷ 4) = 2.5
Result = 2.5 mL
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