Although the client denies pain, the Practical Nurse (PN) observes the client is breathing rapidly with clenched fists and is grimacing. The PN’s best response to his observations would be: * Select one answer

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

Choice A reason: Gives the same message to the patient verbally and nonverbally is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using congruent verbal and nonverbal cues, such as eye contact, tone of voice, and body language, to reinforce the message and avoid confusion or misunderstanding. Therefore, this choice is incorrect.

Choice B reason: Speaks firmly and positively is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings, and needs in a clear, respectful, and confident manner. It also involves using firm and positive language, such as “I” statements, active verbs, and constructive feedback, to convey the message and avoid aggression or passivity. Therefore, this choice is incorrect.

Choice C reason: Is unapologetic is an example of using assertive communication, not a sign of needing further teaching on it. Assertive communication is a communication style that involves expressing one’s thoughts, feelings,

and needs in a clear, respectful, and confident manner. It also involves being unapologetic for one’s opinions, beliefs, or values, as long as they do not harm or disrespect others. It does not mean being rude or arrogant, but rather being honest and authentic. Therefore, this choice is incorrect.

Choice D reason: Agrees to do whatever the patient requests is a sign of needing further teaching on using assertive communication, not an example of it. Agreeing to do whatever the patient requests is a communication style that involves suppressing one’s thoughts, feelings, and needs in order to please or avoid conflict with others. It is a form of passive communication, which can lead to resentment, frustration, or loss of self-esteem. It can also compromise the quality of care or the safety of the patient or the nurse. Therefore, this choice is correct.