The nurse is changing a client’s dressing. Which observation warrants immediate physician notification?

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coffee. The nurse should not delay providing care for a client who may have suffered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coffee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coffee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coffee.

Choice A reason: Be silent as a sign of compassion is not an appropriate action for the nurse to take when a client bursts into tears. Silence can be misinterpreted as indifference, disapproval, or rejection, and it can make the client feel more isolated or uncomfortable. Therefore, this choice is incorrect.

Choice B reason: Continue with the physical preparation of the client is not an appropriate action for the nurse to take when a client bursts into tears. Continuing with the task without acknowledging the client’s emotional state can be perceived as insensitive, uncaring, or disrespectful, and it can increase the client’s anxiety or distress. Therefore, this choice is incorrect.

Choice C reason: Ask the client to share what she is feeling is an appropriate action for the nurse to take when a client bursts into tears. Asking open-ended questions can encourage the client to express her emotions, concerns, or fears, and it can show that the nurse is interested, supportive, and empathetic. It can also help the nurse to identify the source of the client’s distress and provide appropriate interventions or referrals. Therefore, this choice is correct.

Choice D reason: Pull the curtain and leave the area to provide privacy is not an appropriate action for the nurse to take when a client bursts into tears. Leaving the client alone can make her feel abandoned, ignored, or unimportant, and it can prevent the nurse from providing emotional support or assistance. Therefore, this choice is incorrect.