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A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

A.

Use attentive listening with the client.

B.

Focus on the client's present circumstances instead of his personal stories.

C.

Offer the client personal thoughts and beliefs.

D.

Verbalize understanding of how the client feels.

Answer and Explanation

The Correct Answer is A

A. Using attentive listening with the client demonstrates the principle of presence by showing that the nurse is fully engaged and invested in the client's experience, fostering a collaborative relationship.  

 

B. While focusing on the client’s present circumstances is important, the personal stories shared by clients can provide context and enhance understanding, so limiting this aspect is not ideal.  

 

C. Offering personal thoughts and beliefs can shift the focus away from the client and is generally not appropriate in professional communication.  

 

D. While verbalizing understanding is a supportive action, it does not fully encapsulate the principle of presence, which emphasizes active engagement and listening.


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Correct Answer is C

Explanation

A. Verifying the client's room number is not a reliable method of identification, as multiple clients can be in the same room or the client may have been moved.

B. Checking the client's name on the MAR is a good practice but should be combined with a direct method of identification for accuracy.

C. Asking the client for their full name and date of birth is the standard practice for confirming identity before administering medications, ensuring that the nurse is addressing the correct individual.

D. Asking a family member to verify the client's identity is not appropriate, as the nurse must confirm the client's identity personally to maintain safety and accountability.

Correct Answer is D

Explanation

A. Contacting the pharmacy may provide information, but the nurse's primary responsibility is to clarify the prescription with the provider, as they ordered the medication.

B. Informing the charge nurse and administering the medication without verifying the dosage is inappropriate and could potentially harm the client.

C. Asking another nurse to verify the dosage is a good practice but does not address the need for clarification from the provider.

D. Contacting the provider to question the dosage is the correct action, as it ensures patient safety by confirming the appropriateness of the prescribed dose before administration.

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