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. Urinary frequency for several days is an expected outcome after catheter removal, as the bladder may become more sensitive and responsive after having been drained continuously.
B. While temporary urinary retention can occur, it is less common after short-term catheterization, and most clients will start voiding normally within a few hours.
C. Blood-tinged urine may occur occasionally, but it is not a typical expected outcome unless there was trauma or irritation during catheterization.
D. Highly concentrated urine can occur due to dehydration or lack of fluid intake, but it is not a specific expected outcome following catheter removal.
Correct Answer is D
Explanation
A. Injecting the medication 12.7 cm (5 in) below the acromion process is incorrect; the injection site should be approximately 2.5 to 5 cm (1 to 2 inches) below the acromion process.
B. A 21-gauge needle may be appropriate for some IM injections, but a 23- to 25-gauge needle is commonly used for deltoid injections due to the smaller muscle mass.
C. While IM injections into the deltoid are typically given at a 90-degree angle, the volume of medication is the critical factor for this injection site.
D. Injecting a volume of less than 2 mL is correct, as the deltoid muscle can accommodate this amount effectively, while larger volumes should be administered in larger muscles like the vastus lateralis or gluteus medius.