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Delusional disorder refers to fixed, false beliefs that are not based in reality, such as believing one is being persecuted or having grandiose powers. In this case, the client is not expressing a false belief but rather a disorganized and illogical pattern of speech. Therefore, this option does not fit the manifestation described.

Hallucination refers to perceiving something that is not actually present, such as hearing voices or seeing things that others do not. The client’s statement does not describe a sensory experience but rather a disorganized verbal expression. Thus, hallucination is not the correct manifestation here.

Anhedonia is the inability to experience pleasure from activities that are normally enjoyable. The client’s statement does not indicate a lack of pleasure but rather disorganized speech. Therefore, this option does not apply to the scenario.

Informing the client that photographs of injuries are required for a police report is premature and may cause additional distress. While documentation of injuries is important, the nurse’s role is to provide immediate support and allow the client to share their account first. Legal procedures should follow after medical stabilization and consent.

Giving the client a bed bath prior to physical examination is inappropriate because it can destroy forensic evidence needed for legal investigation. Preserving evidence is critical in cases of sexual assault, and cleansing the client before examination would compromise this process.

Discussing self-defense techniques with the client is not appropriate in the immediate aftermath of sexual assault. The priority is to provide emotional support, ensure safety, and preserve evidence. Self-defense education may be useful later but is not part of acute care management.

This adolescent is experiencing significant pain due to sickle cell disease, which is a priority for pain management. However, pain, even when severe, is not immediately life-threatening compared to airway obstruction. The adolescent is stable in terms of airway, breathing, and circulation, so while pain control is important, this client does not require the provider first.

The toddler with asthma has a pulse oximetry reading of 95% while on oxygen. This is slightly below the normal range but still acceptable and not immediately life-threatening. The child is oxygenating adequately, and there is no indication of severe respiratory distress such as retractions, cyanosis, or inability to speak. Therefore, this client does not require immediate provider intervention compared to airway obstruction.

The toddler with otitis media has fever and purulent ear discharge, which indicates infection. While this requires treatment, it is not an emergency. The child is not in respiratory distress, and the condition is not immediately life-threatening. This client can safely wait for provider care after more urgent cases are addressed.

Asking the client to describe the bugs reinforces the hallucination and validates the false perception. This can worsen the client’s anxiety and delusion rather than providing reassurance. It is not therapeutic because it does not orient the client to reality.

Telling the client directly that this is part of withdrawal may be factually correct, but it lacks empathy and does not address the client’s fear. It can come across as dismissive and may increase distress. Therapeutic communication requires acknowledging the client’s feelings while gently reorienting them.

Saying the bugs will not harm the client still validates the hallucination, which is not therapeutic. It fails to reorient the client to reality and may perpetuate the delusion.

Autonomy refers to respecting the client’s right to make decisions about their own care. While autonomy is important in research, discontinuing the medication is not about client choice but about preventing harm.

Justice refers to fairness in treatment and distribution of resources. This principle is not directly demonstrated in the decision to stop the medication.

Fidelity refers to keeping promises and commitments. While important in research, fidelity is not the principle demonstrated in discontinuing a harmful medication.

This statement is prescriptive and dismissive of the nurse’s feelings, implying compliance without exploration. While evidence-based practice is the foundation for policy, invoking it as a directive shuts down dialogue and can contribute to moral distress. It bypasses therapeutic communication, fails to acknowledge the nurse’s perspective, and risks escalating resistance. An effective leader creates psychological safety by fostering open discussion, not enforcing acceptance. This approach also misses an opportunity to identify unintended consequences or implementation barriers that the staff nurse may be experiencing.

This response is retrospective and accusatory, focusing on what the nurse “should have done” rather than addressing present concerns constructively. It can provoke defensiveness and erode trust, discouraging future feedback. In leadership communication, the goal is to understand current issues, validate the nurse’s experience, and engage in problem-solving. Asking why the nurse didn’t speak up earlier implies blame and may ignore systemic factors—such as time pressure, unclear channels for feedback, or fear of reprisal—that can inhibit staff input.

While setting expectations can be part of culture-building, stating it in this manner is general and potentially dismissive of legitimate concerns. It frames the situation as a compliance issue rather than an opportunity to learn from frontline experience. Staff may hear this as “just adapt,” which undermines buy-in and the identification of real barriers. Effective change management emphasizes listening, iterative feedback, and support; a blanket expectation statement does not achieve those aims in the moment of concern.

Asking “why” places the client on the defensive and implies judgment, which can shut down communication. “Why” questions often elicit rationalizations rather than diagnostic detail, and they are less effective than open, neutral prompts. In anxiety assessment, the nurse should prioritize characterizing onset, duration, triggers, severity, functional impairment, and associated symptoms. A neutral, time-focused question helps establish chronology and guides subsequent targeted assessment without assigning blame.

This is a labeling and judgmental statement that violates therapeutic communication principles. It risks stigmatizing the client, exacerbating distress, and damaging rapport. Such phrasing can undermine trust and prevent accurate assessment. Therapeutic communication requires empathy, validation, and neutrality to facilitate disclosure of symptoms, stressors, and coping strategies. Judgments impede the nurse’s ability to gather clinically relevant information and formulate a safe, effective plan.

Redirecting to parents presumes their involvement and may be culturally insensitive or irrelevant for a young adult. It can prematurely shift responsibility away from the nurse’s professional role in assessment and support. The priority is to assess the client’s current symptoms comprehensively and determine safety, impairment, and need for further evaluation. Involving family may be appropriate later, with consent, but it is not the first-line response for establishing a clinical picture.

Discussing alternative treatments is the responsibility of the provider performing the procedure, as part of obtaining informed consent. The nurse should not provide the substantive risk–benefit analysis or alternative interventions, which could be considered practicing beyond scope or create conflicting information. The nurse supports the process by reinforcing education and facilitating questions to the provider but does not originate discussions of alternatives that inform consent.

Assessing and determining the client’s understanding is central to the nurse’s role. The nurse verifies that the client can articulate, in their own words, the nature of the procedure, its purpose, expected outcomes, major risks, benefits, and alternatives, and that consent is voluntary. If gaps or misconceptions are identified, the nurse facilitates clarification by the provider before the client signs. This protects patient autonomy, ensures ethical standards, and upholds legal requirements for valid informed consent.

Explaining procedural risks is the provider’s duty, as only the clinician performing the procedure can fully represent the risks, benefits, alternatives, and expected outcomes specific to the intervention. The nurse may reinforce understanding by encouraging questions or providing general support but should not be the primary source of risk disclosure. Doing so could misrepresent information or exceed scope, potentially invalidating consent if the provider has not adequately informed the client.

A massive head injury with no responsiveness indicates nonsurvivable injury. In mass casualty triage, resources are directed to those who can benefit. This client would be categorized as expectant, not immediate.

An open fracture is serious but not immediately life-threatening. The client is stable and can wait for treatment after airway emergencies are addressed.

A small partial-thickness burn is minor and not life-threatening. This client is the lowest priority in triage.