phases of therapeutic relationship
During this phase, the nurse communicates caring, the patient expresses thoughts and feelings, mutual respect is maintained, and honest verbal and nonverbal expression occurs. Key communication goals are to assist the client to clarify feelings and concerns.
working phase
Communication is a reciprocal process. If your client is unable to express his thoughts clearly, you must be willing to confront him to request clarification. Similarly, you must be willing to be confronted if you are unclear.
Confrontation
Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions.
diagnosis
Which statement or command made by the nurse is an example of the evaluation phase of the nursing process?
A. "I wish Mr. Sullivan were able to walk the length of the hallway by now, but he is not meeting this goal."
B. "Mr. Sullivan will be able to walk the length of the hallway before discharge."
C. "Mr. Sullivan may be able to ambulate with the use of a walker and stand-by assistance."
D. "Ambulate Mr. Sullivan in the hallway three times today, please."
A
Which level of Maslow's hierarchy of need pyramid is necessary for survival?
physiological
gathering information prior to meeting the client
preinteraction phase
•is the ability to respond honestly, involves willingness to self-evaluate. How well did I communicate? Did I handle that situation appropriately? How could I improve my communication?
Genuineness
Mr. Patel was recently started on a new hypertension medication. During a home visit, the nurse asks what Mr. Patel has eaten in the last 24 hours.
assessment
Throughout a nurse's shift, a client has increasing shortness of breath and labored breathing associated with coughing. The client requires frequent repositioning and assistance with activities of daily living. Which is the priority nursing diagnosis for this client?
1.
Ineffective airway clearance
2.
Ineffective breathing pattern
3.
Ineffective coping mechanism
4.
Potential for injury
The client has increased difficulty breathing, which is becoming less effective. The appropriate nursing diagnosis is related to the breathing pattern.
The need to achieve one’s potential; the need for growth and change (e.g., extent to which goals are achieved, role performance)
self actualization
Meeting the client; introductions; establishing rapport and trust
orientation phase
In the therapeutic relationship, you communicate respect by valuing the client and being flexible to meet the client’s needs. As a nurse, you must be willing to adjust to your client rather than expecting the client to adjust to you, the healthcare environment, or
respect
Adrian, a nurse, reflects on her client's admission information, including physical assessment and related family concerns. She considers all information to reach conclusions.
implementation
During an assessment, the nurse notes that the client has an elevated temperature. Which type of data is this?
1.
Subjective
2.
Objective
3.
Secondary
4.
Reported
objective
The need for love and affection (e.g., family, social supports)
Love and belonging.
The conclusion of the relationship, whether at the end of the nurse’s shift or on the client’s discharge from the unit, facility, or service. Reviewing and summarizing help to bring the relationship to a comfortable conclusion.
termination phase
is the desire to understand and be sensitive to the feelings, beliefs, and situation of another person. requires you to be willing to adapt your style, tone, vocabulary, and behavior to create the best approach
Empathy
Mrs. Waters fell in her room at the care center and fortunately was not injured. Documented in her chart was "no further falls will occur while in the care center."
planning outcomes
Which is an appropriate goal statement for a postpartum female client with a nursing diagnosis of "lower abdominal pain r/t uterine contractions and hyperextension of cervix"?
1.
Client will verbalize reduced pain with pain management interventions to a satisfactory level within a 12-hour period
2.
Uterus will cease contracting after treatment within 2 hours
3.
Lower abdominal pain will be relieved by analgesics as prescribed by physician
4.
Client will ambulate to the bathroom at least twice within 8 hours to relieve pressure from abdomen
1.A goal statement begins with a subject (client) and include an action verb (verbalize), performance criteria (reduced pain), and a target time (12-hour period).
fulfilled by master of environment and prestige from societal recognition
Achievement
Status
Responsibility
Reputation
esteem level
gloves, gown, goggles, remove facemark
removing PPE
asking to many question, fire-hoising information, asking why, changing the subject inappropriately, failing to probe, expressing approval or disapproval, offering advice, providing false reassurance ,stereotyping, using patronizing language.
barriers to therapeutic communication.
Upon discharge, the nurse realizes that all care plan goals were met. The documentation is updated to reflect this.
evaluation
Which is a valid goal statement for measuring and managing pain?
1.
The client will not complain of pain.
2.
The nurse will administer pain medication as ordered.
3.
The client will have minimal pain.
4.
The client will report pain greater than level 4 to the nurse.
4. The client will report pain greater than level 4 to the nurse.
Rationale:
The client reporting pain greater than a specific level is a valid, measurable goal.
gown, mask, faceshield, gloves
Donning personal protective equipment (PPE)