The nurse is preparing to start the shift.
For each nurse action, determine if the action corresponds with the pre-interaction, orientation, working, or termination phase.
Reinforce progress toward mobility goals.
Encourage follow-up with outpatient services.
Introduce self and explain role to the client.
Plan how to approach a non-verbal pediatric client.
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"A"}}
Reinforcing progress toward mobility goals occurs during the working phase of the nurse-client relationship. This phase is characterized by the active implementation of the nursing care plan and the achievement of specific health outcomes. The nurse and client work together to solve problems and meet goals. By encouraging movement and celebrating milestones, the nurse is facilitating the client's physical rehabilitation and functional improvement, which is the core objective of the middle stage of the therapeutic relationship.
Encouraging follow-up with outpatient services is a hallmark of the termination phase. This final stage focuses on evaluating the attainment of goals and ensuring a smooth transition of care as the professional relationship ends. Preparing the client for discharge involves consolidating the gains made during the stay and providing the necessary resources for continued recovery. It is the period where the nurse helps the client find the confidence to manage their health independently or elsewhere.
Introducing oneself and explaining the role is the primary task of the orientation phase. This initial meeting sets the tone for the relationship, establishes trust, and defines the boundaries and expectations for both the nurse and the client. During this time, the nurse gathers initial assessment data and identifies the client's immediate needs. The orientation phase is crucial for building a therapeutic alliance, as it is the first opportunity to demonstrate empathy and professional competence.
Planning how to approach a non-verbal pediatric client takes place during the pre-interaction phase. This phase occurs before the nurse ever meets the patient. It involves reviewing the medical record, identifying potential challenges, and preparing the environment or specific communication strategies. By anticipating the needs of a non-verbal child, the nurse can organize thoughts and materials to ensure the first interaction is as effective and less stressful as possible for the young patient. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Sandwich generation refers to the group of middle-aged adults who are simultaneously caring for their aging parents and their own growing children. This situation creates a unique set of stressors, including financial strain and time management challenges, as the individual is squeezed between two generations requiring support. While this occurs during middle age, it does not specifically describe the emotional reaction to children leaving the home for college, which is a different developmental milestone entirely.
Choice B rationale
Caregiver burden is the physical, emotional, and financial stress associated with providing long-term care for an individual with a chronic illness or disability. This term is most often applied to those looking after spouses or parents with conditions like dementia. While it involves significant sadness and exhaustion, it is related to the demands of active caregiving. In contrast, the scenario described involves the absence of caregiving duties as the child moves away, which represents a shift in role.
Choice C rationale
Empty nest syndrome is a psychological condition that can affect parents when their children leave home for the first time, such as for college or marriage. It is characterized by feelings of sadness, loss, and a lack of purpose, as the parent's primary daily role as a caregiver has significantly changed. While not a clinical diagnosis, it is a recognized transition in the family life cycle. Middle-aged adults must often redefine their identity and relationship with their spouse during this period.
Choice D rationale
Role strain occurs when an individual feels pushed in different directions by the competing demands of a single role. For example, a nurse might feel role strain when trying to provide high-quality care while also meeting strict documentation deadlines. This differs from the scenario in the question, which describes a sense of loss following the completion or reduction of a role. The parent is not struggling with too many demands but rather with the emotional void left by the child's departure.
Correct Answer is C
Explanation
Choice C rationale
The statement indicates that the client is experiencing difficulty with the developmental task of accepting themselves as an older adult. This often stems from a societal stigma regarding aging or a personal fear of decline. By distancing themselves from "those people," the client is exhibiting a defense mechanism to avoid the reality of their own aging process. This struggle with self-acceptance can lead to social isolation and may hinder the successful achievement of ego integrity.
Choice A rationale
There is no evidence in the client's statement to suggest that transportation is the primary concern. The client's language specifically focuses on the identity of the people at the center rather than the logistics of getting there. Assuming the issue is transportation would be a clinical error, as it ignores the clear psychosocial message the client is sending about their self-perception. The nurse must address the emotional and cognitive aspects of the client's aging identity first.
Choice B rationale
Refusing to participate in age-appropriate social activities based on a denial of one's own age is not considered a healthy or appropriate self-care behavior. Social engagement is a key component of maintaining cognitive and emotional health in late adulthood. While the client has the right to refuse, the rationale behind the refusal suggests a lack of adjustment to the aging process rather than a proactive choice to engage in a different, more beneficial self-care activity.
Choice D rationale
While denial or confusion can sometimes be seen in cognitive disorders, a single statement regarding age identity is not sufficient evidence to interpret the behavior as early dementia. Dementia involves significant impairment in memory, executive function, and daily living activities. The client's statement is a common psychosocial reaction to aging and should be explored as a matter of self-concept and ego development before jumping to a neurological or psychiatric diagnosis like dementia.
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