The nurse is preparing a teaching plan for a client who is in the implementation step of the teaching plan. Which of the following actions should the nurse take?
Ask the client to demonstrate a skill.
Show the client how to use the incentive spirometer.
Develop a short-term goal for the client.
Assess the client’s pain level.
The Correct Answer is B
Choice A rationale
Asking the client to demonstrate a skill is part of the evaluation step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s ability to perform a skill.
Choice B rationale
Showing the client how to use the incentive spirometer is an appropriate action for the implementation step. This step involves providing education and demonstrating skills to the client.
Choice C rationale
Developing a short-term goal for the client is part of the planning step, not the implementation step. The implementation step involves carrying out the teaching plan, not setting goals.
Choice D rationale
Assessing the client’s pain level is part of the assessment step, not the implementation step. The implementation step involves carrying out the teaching plan, not assessing the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Asking the family member to provide identification does not ensure that the caller is authorized to receive patient information. Even with identification, the nurse cannot verify the caller’s relationship to the patient or their authorization to access confidential information.
Choice B rationale
Not providing any information over the phone is the correct action to protect patient confidentiality. Healthcare providers must ensure that patient information is only shared with authorized individuals, and phone calls do not provide a secure method for verifying the caller’s identity.
Choice C rationale
Providing only publicly available information is not appropriate, as it still involves sharing patient-related details without proper verification. Any disclosure of patient information, even if minimal, must be done with caution and proper authorization.
Choice D rationale
Informing the family member that they need to visit in person is a better approach, but it still does not guarantee that the individual is authorized to receive patient information. The nurse should follow established protocols for verifying authorization before sharing any details.
Correct Answer is C
Explanation
Choice A rationale
Sitting quietly and engaging the client can be supportive, but it may not be sufficient to establish rapport. While presence is important, it lacks the active engagement and therapeutic techniques needed to build a connection.
Choice B rationale
Using open-ended questions starting with “I want time to think and reflect” is not appropriate in this context. Open-ended questions are useful, but the phrasing here is not conducive to therapeutic communication and may confuse the client.
Choice C rationale
Using therapeutic communication techniques is the correct approach. These techniques include active listening, empathy, and validation, which are essential for building rapport and trust with the client. They help the client feel understood and supported.
Choice D rationale
Offering tissues and a comforting presence is supportive but not sufficient on its own. While it shows empathy, it does not actively engage the client in a therapeutic manner to establish rapport.
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