The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?
The relationship occurs spontaneously.
It is based on the needs of the nurse.
The nurse and client will have a social relationship.
The nurse is accountable for the outcome.
The Correct Answer is D
A. The relationship occurs spontaneously: Therapeutic relationships are intentional and structured, unlike spontaneous social interactions.
B. It is based on the needs of the nurse: The relationship is centered on the needs of the client, not the nurse.
C. The nurse and client will have a social relationship: A therapeutic nurse-client relationship is professional, not social. It focuses on supporting the client’s well-being.
D. The nurse is accountable for the outcome: The nurse is responsible for maintaining professional boundaries and ensuring that the relationship supports the client’s health goals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.
B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.
C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.
D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.
Correct Answer is B
Explanation
A. 58-year-old patient with uncontrolled diabetes mellitus type 2 and intact skin: While diabetes increases the risk of delayed wound healing and infection, intact skin is not an immediate concern.
B. 48-year-old patient with poor nutrition, warmth, and edema to the coccyx: Warmth and edema at a pressure site may indicate the beginning of a pressure injury or infection (e.g., cellulitis). Poor nutrition further increases the risk of skin breakdown and impaired healing, making this patient the priority for assessment.
C. 82-year-old patient with a surgical incision and approximated wound edges: A well-approximated surgical incision suggests healing is progressing normally, making this patient lower priority.
D. 69-year-old patient with a colostomy and blanchable erythema to the sacrum: Blanchable erythema is an early sign of pressure injury, but it is less concerning than warmth and edema, which suggest possible infection or worsening tissue damage.
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