When a female client preparing for surgery suddenly bursts into tears, the nurse should take which of the following actions? · Select one answer

Choice A reason: Implementation is a phase of the nursing process that involves carrying out the plan of care and performing the interventions and activities that were planned. It also involves monitoring the client’s response and progress, and documenting the outcomes. The nurse’s actions do not reflect this phase, as they are not performing any interventions or activities, but rather observing and measuring the client’s condition. Therefore, this choice is incorrect.

Choice B reason: Evaluation is a phase of the nursing process that involves measuring the outcomes and determining whether the interventions were effective in resolving or preventing the problem. It also involves comparing the actual outcomes with the expected outcomes, and modifying the plan of care if needed. The nurse’s actions reflect this phase, as they are assessing the client’s leg for signs of improvement or resolution of thrombophlebitis, and noting that the client is ready for discharge. Therefore, this choice is correct.

Choice C reason: Outcomes identification is a phase of the nursing process that involves setting measurable and realistic goals for the client’s health improvement or maintenance. The goals are based on the client’s needs, preferences, and values, and they are developed in collaboration with the client and the nurse. The nurse’s actions do not reflect this phase, as they are not setting any goals, but rather evaluating whether they have been met.

Therefore, this choice is incorrect.

Choice D reason: Assessment is a phase of the nursing process that involves collecting and analyzing data about the client’s health status, history, and environment. It also involves identifying any factors that may affect the client’s health or well-being, and forming a nursing diagnosis. The nurse’s actions do not reflect this phase, as they are not collecting or analyzing any new data, but rather reviewing the existing data and confirming the diagnosis. Therefore, this choice is incorrect.

Choice A reason: "There is no reason to worry. This surgeon has an excellent reputation.” is not the best nursing response. This response shows false reassurance, which is a communication technique that involves minimizing or dismissing the other person’s feelings or situation. It also shows authority, which is a communication barrier that involves using one’s position or status to influence or persuade the other person. It does not address the client’s emotions or needs, and may sound patronizing or condescending. Therefore, this choice is incorrect.

Choice B reason: “It sounds as though you have mixed feelings about the surgery. Can you tell me more about how you feel?” is the best nursing response. This response shows active listening, which is a communication skill that involves hearing, understanding, and responding to the client’s verbal and nonverbal messages. It also shows empathy, which is the ability to understand and share the feelings of another person. It acknowledges and validates the client’s emotions, and invites them to express their concerns or fears. Therefore, this choice is correct.

Choice C reason: "The benefits outweigh the risks. You can be confident that the surgery should be done.” is not the best nursing response. This response shows persuasion, which is a communication technique that involves using logic or evidence to convince or influence the other person. It also shows assumption, which is a communication barrier that involves making judgments or guesses about what the other person thinks or feels. It does not address the client’s emotions or needs, and may sound coercive or manipulative. Therefore, this choice is incorrect.

Choice D reason: "You are bound to feel much beter once it is all over with.” is not the best nursing response. This response shows cliché, which is a communication technique that involves using overused or trite expressions that lack meaning or sincerity. It also shows avoidance, which is a communication barrier that involves shifting the focus away from the other person’s feelings or situation. It does not address the client’s emotions or needs, and may sound vague or insincere. Therefore, this choice is incorrect.