During which phase of the nurse-patient relationship can the nurse anticipate that the patient's identified issues will be explored and resolved?
Working.
Preorientation.
Orientation.
Termination.
The Correct Answer is A
Choice A rationale
The working phase is the central phase of the therapeutic relationship, dedicated to problem identification, exploration of stressors, and the development and testing of new coping mechanisms. It is during this phase that the patient's identified issues are intensely explored and resolved as the nurse and patient work collaboratively towards achieving established goals.
Choice B rationale
The preorientation phase occurs before the first face-to-face encounter. The nurse's activities involve data gathering and self-assessment, such as reviewing the patient's chart, understanding the clinical context, and examining their own feelings, to prepare for the interaction. No direct patient issues are explored or resolved here.
Choice C rationale
The orientation phase is the initial period focused on establishing rapport, clarifying roles, setting goals, and establishing a contract for the relationship. While issues are identified, the in-depth work of exploring and resolving those issues has not yet begun; the foundation is merely being laid.
Choice D rationale
The termination phase is the final stage, focusing on summarizing goals achieved, reviewing the experience, and preparing for separation. The primary goal is to conclude the relationship therapeutically and ensure the patient can maintain gains, not to introduce or resolve new major issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
The Global Assessment of Functioning (GAF) scale is a historical measure used to rate a patient's overall psychological, social, and occupational functioning on a 0–100 continuum. While it provides a comprehensive snapshot of functioning which may be relevant to Major Depressive Disorder (MDD) severity and treatment planning, it is generally used for Axis V of the DSM-IV and is less common as a primary or specific scale for symptom severity in current MDD assessment.
Choice B rationale
The Beck Depression Inventory (BDI-II) is a widely used, 21-item self-report questionnaire specifically designed to assess the severity of depressive symptoms in adolescents and adults. The items directly correspond to criteria for MDD, covering cognitive, affective, somatic, and behavioral symptoms. It has high reliability and validity for screening and measuring the intensity of the disorder, making it a standard tool.
Choice C rationale
The Body Attitude Test (BAT) is an instrument primarily used to measure the subjective body experience disturbance common in patients with eating disorders, such as anorexia nervosa or bulimia nervosa. Although some patients with MDD may experience changes in body image, this scale is not a standardized, specific, or core measure for the general assessment and severity tracking of Major Depressive Disorder.
Choice D rationale
The Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-report tool that systematically screens for the presence and severity of the nine diagnostic criteria for MDD, as outlined in the DSM-5. Its brevity, ease of administration, and excellent sensitivity and specificity make it a preferred, standardized screening and severity monitoring tool for depression in diverse healthcare settings.
Choice E rationale
The Mini-Mental State Examination (MMSE) is a brief, 30-point questionnaire utilized primarily to assess global cognitive function, including orientation, memory, attention, calculation, and language. While cognitive screening is important, the MMSE is a standard for suspected dementia or delirium, not the specific or standardized measure for tracking the core affective and somatic symptoms of Major Depressive Disorder.
Correct Answer is D
Explanation
Choice A rationale
Covert data refers to hidden or non-observable information, often related to internal thoughts, feelings, or unconscious processes. While the MSE may infer aspects of covert data (e.g., through speech patterns), the data collected is primarily based on direct observation and the patient's immediate behavioral and cognitive presentation, making it objective.
Choice B rationale
Subjective data is information provided by the client, such as their feelings, perceptions, or history. While the MSE relies on client reports (e.g., mood, thought content), the final collected data is the examiner's objective description of the client's appearance, motor behavior, speech, and responses observed during the examination.
Choice C rationale
Physical data typically refers to physiological measurements (e.g., blood pressure, heart rate, lab results) or somatic findings. Although general appearance is noted in the MSE, its primary focus is on mental and behavioral status, making "physical" too broad or potentially misleading for the core data collected.
Choice D rationale
The Mental Status Examination (MSE) is a systematic, structured observation and assessment designed to collect objective data about a client's current mental state. This includes observable behaviors like appearance, motor activity, speech, and the examiner's objective description of the client's affect, thought process, and cognitive function.
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