During the initial interview with a client, the nurse notices that the client changes the topic when the subject of the client's marital relationship is approached. The nurse is guided by the knowledge of which of the following?
1. Discussion of sensitive issues should only occur in the working phase.
2. Formulation of nursing diagnoses should be avoided until all essential data is obtained.
3. Information that is avoided or omitted is often more crucial than what is shared.
4. Avoidance of a topic is a sign of resistance that will disappear when initial anxiety is decreased.
3
Rationale: Observation is essential to clinical practice, particularly in one-to-one relationships. Non-verbal behavior and missing information can indicate an area that requires further exploration. Sensitive issues can be discussed in all phases of the therapeutic relationship, particularly if it is valuable in providing direction for nursing care. A preliminary nursing diagnosis should be formulated based on dominant themes or central issues that may be revised as client behaviors unfold during the course of the one-to-one relationship. Resistive behaviors do not commonly disappear on their own and must be addressed openly for the therapeutic nurse–client relationship to progress.
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When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate?
a. "It will be okay. Your surgeon will talk to you in the morning." b. "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"
A client has activated the complement system during an inflammatory response to an injury. When planning care, which information should the nurse remember about which substance activates complement?
1. Histamine 2. Antibodies 3. Leukotrienes 4. Prostaglandins
Which of these actions are appropriate ways to assist the family during this time? Select all
that apply. a. Reassure them that everything will be fine b. Ensure that they have as much privacy as possible c. Encourage them to talk about their feelings, if they can d. Tell them you understand how they are feeling. e. Ask them if they would like to talk with the hospital chaplain and/or social worker f. Remind them that they need to care of themselves to be able to care for their child
The nurse works in a pediatric medical day care centre. An important aspect of the nurse's role is to determine whether children are achieving developmental milestones
Which one of the following characterizes the cognitive development of a 2-year-old child? a. Using short sentences to express independence b. Initiating play with other children c. Recognizing right and wrong d. Having a vocabulary of at least 1000 words