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. Discarding the tablet and obtaining another dose is the safest option, as it ensures the medication's integrity and prevents any potential contamination.
B. Using the tablet's packaging to pick it up is not appropriate as it could introduce contaminants from the surface of the counter to the tablet.
C. Washing the tablet with alcohol is not advisable because it could alter the medication's properties or effectiveness.
D. Placing the tablet directly into a medication cup without addressing its contamination would also be inappropriate and could jeopardize client safety.
Correct Answer is B
Explanation
A. While performing ROM exercises is important for maintaining joint function and circulation, it is not the immediate priority compared to assessing respiratory status.
B. Auscultating breath sounds at least every 2 hours is crucial to monitor for any signs of respiratory compromise, which is a common concern in immobile clients due to the risk of atelectasis and pneumonia.
C. Ensuring adequate fluid intake is important for hydration and preventing complications but is secondary to assessing respiratory function.
D. Applying anti-embolic stockings is important for preventing venous thromboembolism, but respiratory assessment takes precedence in the context of immobility.