A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

b. This must be very frightening for you. Let's talk more about it.

It is important for the nurse to acknowledge the client's fears and show empathy towards them. By saying "This must be very frightening for you," the nurse validates the client's feelings and shows that they are being heard.

Additionally, by suggesting that they talk more about it, the nurse can work towards building a therapeutic relationship with the client and gain more insight into their thought processes.

The other options are not appropriate because:

a. The nurse should not deny the client's beliefs or try to convince them that they are wrong. This can cause

the client to feel invalidated and may make them less likely to trust the nurse.

c. While it is important to understand the client's perspective, this question may come off as confrontational and accusatory.

d. Similarly, this question may be perceived as confrontational and may make the client defensive. It is important to approach the client with empathy and understanding rather than skepticism.

Choice A Reason:

Limiting fluid intake to 750 mL per day is not recommended, as adequate hydration is essential for overall health. The client should maintain good hydration unless specifically advised otherwise by their healthcare provider.

Choice B Reason:

Cleansing the neck by rubbing with a washcloth may be too harsh for the irradiated skin. The skin in the radiation field can become sensitive and may require gentle cleansing with mild soap and patting dry, rather than rubbing.

Choice C Reason:

Eating three large meals each day may not be suitable for all clients undergoing radiation therapy, especially if they are experiencing side effects such as difficulty swallowing or changes in taste. Dietary recommendations should be individualized based on the client's specific needs and symptoms. Smaller, more frequent meals may be more manageable for some clients.

Choice D Reason:

Avoiding exposing the neck to the cold is correct. When providing instructions to a client undergoing radiation therapy to the neck, it's important to emphasize the need to protect the treated area from extreme temperature changes. Exposure to cold temperatures can cause vasoconstriction and potentially lead to tissue damage in the irradiated area. Therefore, advising the client to avoid exposing the neck to cold is a vital precaution.