A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?

Inform the client about confidentiality rights.

Establish boundaries between the nurse and the client.

Set short- and long-term objectives for the future.

Evaluate progress toward predetermined goals.

Answer and Explanation

The Correct Answer is D

A.   Informing the client about confidentiality rights typically occurs during the orientation phase of the therapeutic relationship, not the working phase.
B.   Establishing boundaries between the nurse and the client is an ongoing process that occurs throughout the therapeutic relationship, not just during the working phase.
C.   Setting short- and long-term objectives for the future typically occurs during the orientation phase and continues throughout the therapeutic relationship, not just during the working phase.
D.   During the working phase of the therapeutic relationship, the nurse and client collaborate to achieve the goals identified during the orientation phase. The nurse evaluates the client's progress toward these goals and adjusts interventions as necessary to promote therapeutic outcomes.

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Correct Answer is B

Explanation

A. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.

A. Compensation B. Sublimation C. Regression D. Suppression

Correct Answer is D

Explanation

A. Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B. Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C. Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D. Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.

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Body system	Findings
Neurological	Impaired cognition

	Insomnia Seizures
Cardiovascular	Increased blood pressure Increased heart rate Diaphoresis
Gastrointestinal	Lack of appetite Vomiting
Musculoskeletal	Malaise Tremulousness

A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

A nurse is caring for a client who has been taking quetiapine for 1 week and reports dizziness. The client asks the nurse if the dizziness indicates an allergic reaction to the medication. Which of the following responses should the nurse make?

A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

A nurse is caring for a client who is taking citalopram. For which of the following adverse effects should the nurse monitor the client?

A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)