The nurse instructs the nursing assistant to obtain temperatures on four patients and report abnormal findings immediately. Two hours later the nurse discovers that one of the patients had a fever that was not reported. The nurse is upset with the nursing assistant. Which statement, if made by the nurse, is concrete and specifically explains the nurse's feelings?

Correct Answer: C

Rationale: The correct answer is C: "I am disappointed because you did not follow my directions." This statement directly addresses the issue by highlighting the nursing assistant's failure to follow instructions, leading to the unreported fever. The nurse expresses disappointment, which is a concrete feeling based on the specific situation. Explanation: 1. "I am not dissatisfied with your performance, because we all make mistakes." - This choice downplays the seriousness of the situation and fails to address the specific issue of not following directions. 2. "You must have misunderstood. I wanted to know about any elevated temperatures." - This choice implies a possible misunderstanding without directly addressing the failure to report the fever. 3. "I am disappointed because you did not follow my directions." - This choice directly states the reason for the nurse's feelings, linking the disappointment to the nursing assistant's failure to report the fever. 4. "You have made me so angry. Why did you not report the fever to me?" - This choice uses

Correct Answer: D

Rationale: The correct answer is D because it provides clear, specific instructions for the nursing assistant on when to notify the nurse about Mr. Jones' condition. It includes a specific parameter (heart rate greater than 100) which helps in identifying the urgency of the situation. Options A, B, and C are vague and lack specificity, making it difficult for the nursing assistant to know when to escalate the situation. Option D ensures effective communication and appropriate delegation by setting clear expectations for when the nurse needs to be notified.

Correct Answer: B

Rationale: Step 1: Asking the client to report the amount of fluid intake for the past 24 hours is the most appropriate action because it provides objective data on the client's adherence to fluid restrictions. Step 2: This information helps the nurse to assess the client's compliance and make informed decisions about the next steps in care. Step 3: By obtaining accurate information on fluid intake, the nurse can identify any discrepancies between prescribed fluid restrictions and actual intake, leading to appropriate interventions. Step 4: This action promotes client accountability and empowers them to take an active role in managing their health. In summary, choice B is correct as it directly addresses the issue of non-adherence to fluid restrictions by gathering crucial information for assessment and intervention. Choices A, C, and D do not provide immediate actionable data on the client's fluid intake and do not address the core issue effectively.

Correct Answer: C

Rationale: The correct response is C: "It sounds like you really made a connection with Ms. C." This response acknowledges the student's positive interaction with the patient, encouraging empathy and recognizing the importance of building therapeutic relationships in nursing practice. By showing support and validation for the student's connection with the patient, it fosters a positive learning experience and reinforces the value of patient-centered care. Choice A is incorrect as it deflects responsibility onto the instructor and does not address the student's interaction with the patient. Choice B puts the focus on the student's opinion rather than acknowledging the relationship with the patient. Choice D is incorrect as it dismisses the student's connection with the patient and does not encourage the development of a therapeutic relationship.

Correct Answer: B

Rationale: The correct answer is B: Assertive, responsible, and caring communication. This approach is effective because it involves setting clear boundaries (assertive), taking ownership of the situation (responsible), and showing empathy and support (caring). By being assertive, the nurse can communicate expectations clearly. Being responsible conveys accountability and encourages the patient to take ownership of their health. The caring aspect fosters a supportive environment, making the patient feel understood and motivated to change. Choice A (Authoritative, honest, and outright communication) may come off as too forceful and may not promote cooperation. Choice C (Aggressive, sympathetic, and realistic communication) is contradictory - being aggressive does not align with being sympathetic. Choice D (Positive, expert, and focused communication) lacks the element of assertiveness needed to set clear boundaries and expectations.

Correct Answer: B

Rationale: The correct answer is B: Use a direct approach with succinct sentences. This is the most effective communication strategy because it promotes clear and concise communication, which is essential when discussing concerns related to client care. By using a direct approach, the nurse can effectively convey her message to the physician without any confusion or ambiguity. Choice A is incorrect because assuming a subservient role can undermine the nurse's professionalism and confidence. Choice C is incorrect because asking questions instead of making recommendations may not effectively address the concern at hand. Choice D is incorrect because politeness alone may not ensure effective communication if the message is not clearly articulated.

Correct Answer: B

Rationale: The correct answer is B because the client is indirectly asking for information on how to make food taste better without explicitly mentioning sodium or low-sodium diet. Choices A, C, and D are direct requests for information related to sodium intake, blood pressure control, and high-sodium foods, respectively. By choosing B, the client is hinting at the need for flavorful alternatives without directly addressing the issue of sodium restriction. This indirect approach suggests a desire to maintain taste while adapting to a low-sodium diet.

Correct Answer: C

Rationale: The correct answer is C: Request a Spanish-speaking medical interpreter. This is the best action because it ensures accurate and effective communication between the nurse and the patient, maintaining patient confidentiality and preventing misinterpretation. Using a bilingual friend of the patient (A) may lead to bias or inaccurate translation. Nonverbal communication and drawing pictures (B) may not convey complex medical information effectively. Interviewing the patient's English-speaking daughter (D) may result in miscommunication and potential inaccuracies in the health history.

Correct Answer: D

Rationale: The correct answer is D because addressing the client's concerns directly with the healthcare provider (HCP) is the most immediate and effective way to ensure proper infection control procedures are followed. By approaching the HCP and explaining the client's observations and concerns, the team leader can facilitate communication and potentially prevent any lapses in infection control. This action promotes patient safety and trust in the healthcare team. Choice A is incorrect because assuming the HCP washed hands without confirmation can lead to overlooking potential gaps in infection control. Choice B is incorrect as it does not address the client's specific observation and concerns. Choice C is not the priority as contacting infection control should come after addressing the issue with the HCP directly.