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?
Use attentive listening with the client.
Focus on the client's present circumstances instead of his personal stories.
Offer the client personal thoughts and beliefs.
Verbalize understanding of how the client feels.
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 A
Explanation
A. Checking the client for allergies is the first step in ensuring the safety of medication administration; it is crucial to verify that the client does not have any known allergies to the medication before proceeding.
B. Documenting that the medication was administered should occur after the medication has been given, not before.
C. Mixing the medication at the client’s bedside is an important step, but it should be done only after confirming that the medication is appropriate for the client.
D. Determining the client's response to the medication occurs after administration, making it a follow-up action rather than a first step.
Correct Answer is ["B","D","E"]
Explanation
A. Assessing the client every 4 hours is insufficient; the nurse should assess the client more frequently to monitor for changes in condition and risk factors for falls.
B. Placing a fall-risk identification band on the client's wrist is essential for alerting all staff to the client's fall risk, thereby promoting safety.
C. Keeping the client's room dark at night increases the risk of falls; adequate lighting should be provided to help the client navigate safely.
D. Teaching the client to use the call light encourages them to seek assistance when needed, which can help prevent falls.
E. Keeping the client's bed in the lowest position minimizes the risk of injury if the client attempts to get out of bed without assistance.