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: A

Rationale: The correct answer is A because it demonstrates empathy and validates the patient's emotions. Acknowledging the patient's fear shows understanding and support, which is essential in therapeutic communication. Choice B gives false hope and may not be accurate. Choice C dismisses the seriousness of the diagnosis. Choice D is unrelated and does not address the patient's emotional needs. In summary, choice A is therapeutic as it shows empathy and support, while the other choices are either inaccurate, dismissive, or irrelevant.

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: 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: 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: A

Rationale: Rationale: - Choice A is correct because it is nonassertive and implies a desire for control over others' schedules, which may frustrate the nurse manager. - Choice B is incorrect because it shows indifference, not assertiveness. - Choice C is incorrect as it expresses a clear preference without being nonassertive. - Choice D is incorrect because it is assertive but in a negative and confrontational way.

Correct Answer: A

Rationale: The correct answer is A because maintaining eye contact shows respect and attentiveness towards the client. It demonstrates active listening and helps build trust. Choice B is incorrect as avoiding touch may convey fear or stigma towards the client. Choice C is incorrect as it may create a sense of isolation rather than respect. Choice D is incorrect as small talk about the weather may not necessarily show genuine respect for the client's situation. Overall, maintaining eye contact is a universal sign of respect and connection in communication.

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 using high levels of intimacy with a client in a professional setting is inappropriate and can violate boundaries. The nurse should maintain a professional relationship with the client to ensure ethical standards are upheld. A: Reminiscing about birthday celebrations is appropriate as it can help build rapport and show empathy towards the client. C: Sharing a personal story to establish trust is acceptable as long as it is relevant to the client's situation and does not breach confidentiality. D: Sharing information about meditation decreasing nausea during chemotherapy treatment is relevant and can provide valuable support to the client.