Correct Answer: A

Rationale: The correct answer is A because documenting the frequency of assessments and interventions for high-risk patients, such as those at risk for falls, is crucial for patient safety and care coordination. By documenting more frequently for high-risk patients, nurses can ensure timely interventions and prevent adverse events. This practice aligns with the principles of patient-centered care and risk management. Choices B, C, and D are incorrect: B: Avoiding labels in documentation is important for professionalism and ethical practice, but it is not directly related to the frequency of documentation for high-risk patients. C: Detailed and specific documentation is required for all patients to ensure comprehensive care, not just for potential malpractice suits. D: While clear and concise documentation is essential, this choice does not specifically address the need for more frequent documentation for high-risk patients.

Correct Answer: D

Rationale: The correct answer is D: summarizing. Summarizing involves presenting the problem and potential solutions to the patient in a clear and concise manner. In this scenario, the nurse is summarizing the patient's thoughts and concerns about notifying their daughter of the upcoming surgery. By doing so, the nurse is helping the patient to make a decision by clarifying the situation and potential options. This technique allows the patient to reflect on the information presented and make an informed choice. A: Focusing involves directing the conversation to a specific topic or issue. B: Reflection involves restating the patient's feelings or thoughts to show understanding. C: Restatement involves repeating the patient's words to confirm understanding. Therefore, the correct answer is D because summarizing is the technique being used in this scenario to help the patient make a decision regarding notifying their daughter about the upcoming surgery.

Correct Answer: C

Rationale: The correct answer is C. It is crucial for healthcare professionals to maintain professional boundaries with patients to ensure ethical practice and prevent potential harm. By telling the patient that the relationship must remain professional, the nurse sets clear boundaries and maintains the integrity of the therapeutic relationship. This approach protects both the patient and the nurse from potential ethical violations. Choice A is incorrect because encouraging the behavior could lead to boundary violations and harm the therapeutic relationship. Choice B is not the most appropriate immediate action as it does not address the situation directly with the patient. Choice D is also not the best course of action as transferring the patient does not address the underlying issue of maintaining professional boundaries.

Correct Answer: D

Rationale: The correct answer is D because developing a plan of care and measurable objectives with the patient promotes patient-centered care, encourages collaboration, and ensures the patient's active involvement in their own care. This approach respects the patient's autonomy and preferences, fosters shared decision-making, and enhances treatment adherence. A: Demonstrating human caring by hugging the patient may not be appropriate as it can violate professional boundaries and personal space. B: Disclosing shared intimate details with other healthcare providers breaches patient confidentiality and violates privacy rights. C: Maintaining a physical distance of at least 3 to 4 feet at all times may be necessary for infection control but does not address the core aspect of involving the patient in their care plan.

Correct Answer: C

Rationale: The correct answer is C: Functional ability. This is because the priority nursing concept to consider in planning interventions for Ms. C is her ability to independently perform colostomy care. By refusing to demonstrate, she may be indicating a lack of functional ability to manage this aspect of self-care. This is essential for her long-term independence and quality of life. Mobility (choice A) is important but not the priority in this case. Tissue integrity (choice B) is also crucial but not as immediate as ensuring functional ability. Coping (choice D) is important for emotional well-being but does not address the primary issue of functional ability for self-care.