What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

Establish rapport and develop treatment goals.

Acknowledge the client's actions, and generate alternative behaviors.

Explore how thoughts and feeling about this client may adversely impact nursing care.

Attempt to find alternative placement.

Answer and Explanation

The Correct Answer is A

a. Establish rapport and develop treatment goals: During the orientation phase, the primary focus is on building trust and rapport with the client. Establishing rapport and developing treatment goals are essential to creating a therapeutic alliance and setting the stage for effective treatment.
b. Acknowledge the client's actions, and generate alternative behaviours: This action is more appropriate during the working phase, where the nurse and client work on behavior change and coping strategies.
c. Explore how thoughts and feelings about this client may adversely impact nursing care: This is part of the nurse's self-reflection and supervision but is not the priority during the orientation phase.
d. Attempt to find alternative placement: This may be considered if the current setting is unsuitable, but it is not the primary focus of the orientation phase.

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Correct Answer is D

Explanation

a. "We can keep the scatter (throw) rug in the bathroom for safety." This is incorrect because scatter rugs are a fall hazard and should be removed.
b. "One family member should provide all care for the client when at home." This is incorrect because caregiving should ideally be a shared responsibility to prevent caregiver burnout.
c. "We should leave food by the bedside in case the client gets hungry." This is incorrect because it can pose choking hazards and does not address proper supervision for eating.
d. "We can use respite care for short term relief for caregiving." This is correct as it shows understanding of the importance of respite care to prevent caregiver burnout and ensure sustained quality care for the client.

A. "You need to understand there are no voices" B. What are the voices telling you to do? C. What do you think is causing you to heal the voices? D. "You need to tell the forces to leave you alone.

Correct Answer is B

Explanation

a. "You need to understand there are no voices": Denying the client's experience can be invalidating and unhelpful.
b. What are the voices telling you to do? (Correct)A key principle in responding to someone experiencing auditory hallucinations is to validate their experience and ask open-ended questions. This helps the client feel heard and allows the nurse to assess the severity of the situation and potential safety risks.
c. What do you think is causing you to hear the voices? While exploring the cause of hallucinations can be part of therapy, in the immediate situation, focusing on what the voices are saying and assessing safety is more important.
d. "You need to tell the forces to leave you alone": This is confrontational and doesn't acknowledge the client's fear. It might also reinforce the belief in the voices having power.

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What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is giving discharge instructions to the family of a client diagnosed with a neurocognitive disorder. The nurse includes the client's family. Which statement by the family would indicate that teaching has been effective? The family states:

Correct Answer is D

Explanation

A client who has schizophrenia is talking to the nurse and states, "Do you hear that? I am scared. The voices are telling me to do horrible things which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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What should be the priority nursing action during the orientation (introductory) phase of the nurse-client relationship?

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