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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Apply restraints to the patient's wrists. Restraints should be a last resort and only used when all other interventions have failed. Before restraining, less restrictive methods such as reorientation, supervision, and environmental modifications should be attempted first.

B. Turn on the patient’s bed alarm. While a bed alarm can alert staff if the patient attempts to get out of bed, it does not prevent the patient from pulling at their dressings and IV lines. More direct supervision is needed.

C. Administer a sedating medication. Sedation should be used cautiously, as it may increase the risk of falls, delirium, and respiratory depression. Non-pharmacologic interventions should be attempted first unless the patient is a danger to themselves or others.

D. Move the patient closer to the nurse’s station. This is the best first intervention. Placing the patient closer to the nurses' station allows for increased supervision and quicker intervention while also helping to reduce agitation through reassurance and reorientation.

A. 46-year-old with a low neutrophil count B. 59-year-old seven days post abdominal surgery C. 82-year-old with a history of leukemia ten years ago D. 62-year-old on antibiotic therapy

Correct Answer is A

Explanation

A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.

B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.

C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.

D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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