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.
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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Related Questions
Correct Answer is B
Explanation
a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.
Correct Answer is D
Explanation
a. Hypoglycaemia can occur, but it is not as immediately life-threatening as cardiac dysrhythmia.
b. Endocrine imbalance and amenorrhea are significant but not usually immediately life-threatening.
c. Cold intolerance due to decreased metabolism is uncomfortable but not immediately life-threatening.
d. Cardiac dysrhythmias are a major health complication of anorexia nervosa due to electrolyte imbalances, particularly hypokalaemia, which can lead to cardiac arrest. This is a life-threatening condition that needs to be monitored closely.
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