The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:
termination phase.
orientation phase.
working phase.
preinteraction phase.
The Correct Answer is B
B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.
A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.
C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.
D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.
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Correct Answer is D
Explanation
D. Congruent communication occurs when verbal and nonverbal messages are consistent with each other. In the scenario, the nurse's direct eye contact, pleasant expression, and verbal statement ("The colostomy looks good") appear to be aligned and supportive of each other. This demonstrates congruence in communication, where both verbal and nonverbal cues are reinforcing a positive message to the client.
A. Introductory communication typically refers to the initial phase of interaction where the nurse establishes rapport, introduces themselves, and sets the tone for the interaction. This does not directly apply to the nurse's actions described in the scenario of changing a client's colostomy bag.
B. Noncongruent communication occurs when there is a mismatch between verbal and nonverbal messages. In this scenario, the nurse makes direct eye contact, has a pleasant expression, and verbally reassures the client that "the colostomy looks good." If these nonverbal cues (eye contact, pleasant expression) are not aligned with the verbal message (reassuring statement), it would be noncongruent communication. However, based on the scenario, it seems the nurse's nonverbal cues (eye contact, pleasant expression) support the verbal message, so this option is less likely.
C. Nonverbal communication includes gestures, facial expressions, eye contact, body language, and tone of voice. In the scenario described, the nurse demonstrates nonverbal communication by making direct eye contact and having a pleasant expression while interacting with the client. Nonverbal communication is an important aspect of nursing care as it conveys empathy, reassurance, and attentiveness to the client's needs.
Correct Answer is C
Explanation
C. Chvostek's sign is assessed by tapping or lightly percussing the facial nerve (facial muscles) at the angle of the jaw, just in front of the earlobe. A positive Chvostek's sign is indicated by facial twitching, especially around the mouth, nose, and eye, in response to this percussion. It indicates neuromuscular irritability due to low calcium levels.
A. Straining urine is typically done to collect urine for analysis or to detect urinary stones. It does not relate to the assessment of neuromuscular irritability, which is what Chvostek's sign evaluates.
B. This option does not pertain to assessing Chvostek's sign either. Inflating a blood pressure cuff above systolic measurement is a technique used to assess for Trousseau's sign, which is another clinical indicator of hypocalcemia but involves different physiological mechanisms than Chvostek's sign.
D. This option is unrelated to assessing Chvostek's sign or hypocalcemia. Baseline height and weight are typically obtained for nutritional assessment, growth monitoring, or as part of a general health assessment. They do not help in evaluating neuromuscular irritability associated with calcium levels.
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