A nurse in a pediatric clinic is reviewing the laboratory results of a school-age child. Which of the following findings indicates the child may have a potential bacterial infection?

Rationale:

A. "Your family disagrees with your decision?": This open-ended response reflects therapeutic communication by encouraging the client to express her feelings without judgment. It invites further discussion and shows the nurse’s support for the client’s autonomy and emotional well-being.

B. "Did you tell your provider that your family doesn't agree with your decision?": This response shifts focus away from the client's emotional conflict and places it on the provider. It may dismiss the client’s current need for support and hinder further emotional exploration.

C. "You are making the same decision I would make.": Personalizing the conversation undermines client autonomy. The nurse’s role is to support the client’s decision-making process, not impose personal opinions or make assumptions about what is best.

D. "You should get your family to agree with your decision before signing the consent.": This response suggests the client must yield to family opinions, which contradicts the principle of informed consent. The decision is ultimately the client’s, and family agreement is not a legal or ethical requirement.

Rationale:

A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.

B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.

C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.

D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.