A nurse is caring for a client who follows a kosher diet.
Which of the following menu items should the nurse include on the tray?

Choice A rationale: Countertransference is not the appropriate concept in this scenario. Countertransference refers to the nurse's emotional response to the client, which may be based on the nurse's unresolved issues and can negatively affect the therapeutic relationship. In this case, the nurse's actions are not driven by unresolved issues but by a desire to meet the client's basic needs.

Choice B rationale: Promoting trust is the most suitable explanation for the nurse's actions. By interrupting the bath and providing a healthy meal to a newly admitted client who hasn't eaten all day, the nurse is demonstrating empathy, compassion, and a commitment to meeting the client's physiological needs. This action helps build trust between the nurse and the client, as the client can see that their well-being is a priority.

Choice C rationale: Boundary crossing refers to actions that may blur or violate professional boundaries between a nurse and a client. While the nurse is going beyond the routine bath to provide a meal, this action is justified by the client's immediate need and doesn't constitute an inappropriate boundary crossing. The nurse is still maintaining professionalism in caring for the client.

Choice D rationale: Veracity is the principle of truth-telling and honesty in healthcare. It doesn't directly apply to this situation since the nurse's actions are not about providing information or disclosing something to the client. Instead, the nurse's primary concern is the client's nutritional well-being.

The correct answer is Choice C.

Choice A rationale: Quoting client comments when documenting provides accurate and direct information. It ensures the client's exact words are recorded, which is important for clear communication among healthcare providers and for legal documentation.

Choice B rationale: Documenting medication administration should occur immediately after giving the dose, not prior. This ensures accuracy and prevents potential errors or omissions, maintaining the integrity and safety of the client's medical record.

Choice C rationale: Documenting information telephoned in by a nurse who left the unit ensures continuity of care. It accurately records details that may be critical to the client's treatment and care plan, ensuring that all healthcare providers have up-to-date information.

Choice D rationale: Limiting documentation to subjective information is not sufficient. Comprehensive documentation should include both subjective (client's statements) and objective (measurable data) information to provide a complete and accurate picture of the client's condition and care.