The nurse is providing discharge education to a client.The client is slouched in their chair, yawning and not making eye contact.
What action should the nurse take?
Offer written materials for later review.
Reschedule the session.
Ask the client if they need a break.
Continue the session.
The Correct Answer is C
Choice A rationale
Offering written materials for later review is helpful but does not address the client's current physiological state or their lack of engagement. If the client is too tired to process information, simply handing over papers may result in the information being ignored or misunderstood. The nurse should first address why the client is slouched and yawning. Effective education requires an active and receptive learner, and written materials should supplement verbal instruction rather than replace it.
Choice B rationale
Rescheduling the session might be necessary, but it should not be the first action without further assessment. The nurse needs to determine if the client is briefly tired or if there is a more significant barrier to learning. Automatically rescheduling could delay essential discharge information that the client needs for safety at home. Asking for clarification about the client's needs allows the nurse to make an informed decision about whether to continue or find a better time.
Choice C rationale
Asking the client if they need a break is the most appropriate action because it acknowledges the client's non-verbal cues of fatigue. This approach demonstrates empathy and allows the nurse to assess the client's readiness to learn. It provides the client an opportunity to express if they are overwhelmed, tired, or in pain. Adjusting the teaching plan based on the client's immediate needs ensures that the education provided is actually received and retained by the client.
Choice D rationale
Continuing the session while the client is clearly disengaged is ineffective and a poor use of nursing time. Learning cannot occur if the client is unable to concentrate or is physically exhausted. Persisting with the education despite signs of fatigue may cause the client to miss critical information regarding their care and recovery. The nurse must be sensitive to the client's capacity to absorb information and should modify the teaching strategy when signs of disinterest or exhaustion appear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
This statement reflects magical thinking, which is common in the pre-school years. The child believes that their thoughts alone have the power to cause external events to happen. While magical thinking and animism are both features of the preoperational stage, they are distinct concepts. This specific belief about monsters focuses on the causal power of the mind rather than attributing life, feelings, or intentions to an inanimate object like a toy or doll.
Choice B rationale
This statement is an example of egocentrism, where the child assumes that others see, hear, and feel exactly the same way they do. The child is unable to take the perspective of another person, believing their own preferences are universal. While this is a core characteristic of Piaget's preoperational period, it does not involve the personification of objects. Egocentrism is about the lack of perspective-taking rather than the attribution of life to non-living things.
Choice C rationale
Animism is the belief that inanimate objects have lifelike qualities, such as feelings, thoughts, and intentions. By stating that the doll is "sad," the child is projecting human emotions onto a plastic or cloth object. This is a classic developmental milestone in the preoperational stage as the child tries to make sense of the world. It shows they are using their imagination to give personality to objects that do not possess biological life.
Choice D rationale
This statement illustrates symbolic play or pretend play. The child is using one object, a box, to represent something else, a car. This is a vital cognitive step where the child uses symbols to stand for real-world items. Although it is a hallmark of the preoperational stage, it is not animism because the child is not necessarily claiming the box is alive or has feelings; they are simply using it as a prop.
Correct Answer is B
Explanation
Choice A rationale
Focusing on tasks instead of the client's feelings describes a task-oriented approach rather than a therapeutic relationship. While completing clinical tasks is necessary for physical care, the therapeutic relationship requires a focus on the client's subjective experience and emotional well-being. Neglecting the client's feelings can lead to a sense of depersonalization, where the individual feels like a set of symptoms rather than a human being. Empathy and active listening are the drivers of therapeutic success.
Choice B rationale
Maintaining clear and professional boundaries is the foundation of a safe and effective nurse-client relationship. These boundaries protect both the client and the nurse by ensuring that the focus remains entirely on the client's therapeutic goals. Boundaries define the limits of the professional role and prevent the relationship from becoming personal or exploitative. Without these limits, the nurse's objectivity may be compromised, and the client may feel confused about the nature of the support they are receiving.
Choice C rationale
Discussing the nurse's personal life with the client is known as self-disclosure and should be used very sparingly, if at all. When a nurse talks about their own problems or life events, the focus shifts away from the client. This can burden the client with the nurse's issues and blur the professional lines of the relationship. A therapeutic relationship must be client-centered, meaning every interaction is intentionally designed to benefit the client rather than satisfy the nurse's social needs.
Choice D rationale
Establishing social friendships with the client is a violation of professional boundaries and can lead to unethical situations. A therapeutic relationship is asymmetrical by nature, as it exists to serve the needs of the client through the nurse's expertise. Friendships imply a mutual exchange of support and a social equality that does not fit the clinical context. Converting a professional connection into a friendship can impair the nurse's clinical judgment and create dependencies that hinder the client's independence.
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