A nurse is discussing the components of the working phase of the nurse-client relationship with a client. Which of the following tasks are specific for this stage to create a therapeutic environment?
Reviewing client education
identifying problem-solving skills
Summarizing the goals and objectives achieved
Specifying a contract
The Correct Answer is B
A. Reviewing client education: Reviewing education is often part of the termination phase, where teaching is reinforced and the nurse ensures the client understands care plans after the therapeutic relationship ends. It is not a primary focus during the working phase.
B. Identifying problem-solving skills: The working phase focuses on active problem-solving, setting goals, and implementing strategies to address the client's issues. This is when trust is established further, and the nurse and client collaborate on interventions and coping techniques to promote positive outcomes.
C. Summarizing the goals and objectives achieved: Summarizing achievements is part of the termination phase, when the nurse and client reflect on progress made. It helps bring closure to the relationship but does not belong to the working phase where the focus is still on active progress.
D. Specifying a contract: Specifying a contract is a task of the orientation phase, where the structure of the nurse-client relationship, roles, and expectations are defined. This lays the foundation before entering into the problem-solving focus of the working phase.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "I will use a sitz bath at least once a day.": Sitz baths should be used more frequently, typically several times a day, to promote perineal healing, relieve discomfort, and reduce swelling after an episiotomy. Limiting it to once daily may not provide adequate relief or hygiene support.
B. "I will check the amount of bleeding with every other pad change": The amount of lochia (postpartum bleeding) should be checked with every pad change, not every other. Monitoring bleeding closely helps detect signs of hemorrhage or infection early, ensuring prompt intervention if abnormalities are found.
C. "I will wash my perineum with mild soap and warm water every other day.": Perineal hygiene should be performed daily, and often multiple times a day, especially after urination or bowel movements. Washing every other day is insufficient and could increase the risk of infection at the episiotomy site.
D. "I will change my pad at least three times a day": Changing the perineal pad at least three times daily, or more often as needed, maintains cleanliness, helps prevent infection, and allows for regular monitoring of lochia and healing. This statement demonstrates good understanding of postpartum perineal care.
Correct Answer is D
Explanation
A. Decreased bowel sounds: Decreased bowel sounds are often associated with conditions like ileus, abdominal surgery, or bowel obstruction, rather than directly indicating fluid volume excess. Fluid overload typically affects the cardiovascular and respiratory systems first.
B. Urine output of 360 mL/12 hr: While this is a low urine output and could suggest dehydration or renal impairment, it is more indicative of fluid volume deficit rather than fluid volume excess. Excess fluid volume would generally be associated with adequate or increased urine output if renal function is normal.
C. Blood pressure of 100/74 mm Hg: This blood pressure reading is within normal limits for many adults and does not specifically suggest fluid overload. In cases of fluid volume excess, a client might actually exhibit elevated blood pressure due to increased circulatory volume.
D. Distended neck veins: Distended neck veins, also known as jugular venous distention, are a classic sign of fluid volume excess. They occur because increased intravascular volume causes elevated venous pressure, which becomes visible in the neck veins when the client is positioned at a 30- to 45-degree angle.
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