A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Choice A rationale

Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they

are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.

Choice B rationale

Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.

Choice C rationale

Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.

Choice D rationale

Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.

Choice A rationale

Cleaning the catheter after each use with soap and water is a crucial step in preventing infection during self-catheterization.

Choice B rationale

The angle at which the penis should be held during catheter insertion can vary, but a 30 to 45- degree angle is not typically recommended.

Choice C rationale

Performing catheterization when feeling the urge to void is not typically part of the instructions for clean intermittent self-catheterization.

Choice D rationale

Inflating the balloon when the urine flow stops is not a step in clean intermittent self- catheterization. This step is associated with indwelling catheters, not intermittent catheters.