The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the termination phase with a client?
"After breakfast we can review the instructions for insulin self-injection again."
"As soon as I get your admission papers I'll be in to talk with you about your health problem."
“I see that you live near the hospital. Have you been living here a while?"
“I’m going to miss talking with you every day but you are better and ready to go home now."
The Correct Answer is D
A. "After breakfast we can review the instructions for insulin self-injection again.": This statement indicates ongoing interaction and teaching with the client, suggesting that the nurse is still in the working phase of the nurse-client relationship rather than the termination phase.
B. "As soon as I get your admission papers I'll be in to talk with you about your health problem.": This statement implies the initiation of a relationship and care plan, indicating that the nurse is in the orientation phase rather than the termination phase.
C. “I see that you live near the hospital. Have you been living here a while?": This statement reflects rapport-building and exploration of the client’s background, which are part of the initial phases of the nurse-client relationship. It does not signify the termination phase.
D. “I’m going to miss talking with you every day but you are better and ready to go home now.": This statement clearly indicates the termination phase of the nurse-client relationship. It acknowledges the emotional aspect of the relationship while confirming that the client is prepared for discharge, signifying the conclusion of the care provided. This reflects a transition in the relationship as the nurse prepares to end interactions with the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Move the client's limbs through their complete range of motion: This action describes passive range-of-motion exercises, where the nurse assists the client in moving their limbs. While this is beneficial for clients who cannot move independently, it does not align with the plan for isometric exercises, which focus on muscle contraction without joint movement.
B. Have the client move each limb independently through its complete range of motion: This describes active range-of-motion exercises, which involve the client actively moving their limbs. Although these exercises are important for maintaining joint flexibility and preventing stiffness, they are not isometric exercises, which are intended to be performed without changing the length of the muscle.
C. Ask the client to move her arms and legs while applying slight resistance: This action combines movement with resistance training, which is not consistent with isometric exercises. Isometric exercises focus solely on muscle contraction without joint movement or changing muscle length, making this option inappropriate for the prescribed plan of care.
D. Instruct the client to tighten muscle groups for a short period, and then relax: This accurately describes isometric exercises, where the client contracts specific muscle groups (e.g., arms, legs, abdomen) without moving the joints. These exercises help maintain muscle strength and prevent atrophy while the client is on bedrest. The nurse should guide the client to perform these contractions for a few seconds, followed by relaxation, as directed by the plan of care.
Correct Answer is B
Explanation
A. The vein appears cordlike: A cordlike appearance of the vein can indicate phlebitis or thrombosis rather than an infection. While this finding may be associated with complications related to an IV catheter, it does not specifically indicate an infection at the insertion site.
B. Purulent drainage is noted from the site: The presence of purulent drainage is a clear sign of infection. Purulent drainage typically indicates the accumulation of pus, which is a result of the body's immune response to infection. This finding aligns with the expectation of an infection at the IV catheter insertion site.
C. The client reports numbness at the site: Numbness is not a common symptom of infection. It may indicate nerve involvement or irritation, which could be related to the placement of the catheter, but it does not directly signify an infection at the insertion site.
D. Skin over the site is sloughing: Sloughing skin may indicate severe tissue damage or necrosis, which could occur in cases of severe infection, but it is not a typical finding in a localized infection at the insertion site. More commonly, an infection would present with redness, warmth, swelling, and possibly purulent drainage.
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