A patient states, "I'm so worried that I might have cancer." The nurse responds, "It is time for you to eat breakfast." The nurse's response is an example of.
judgmental response.
using clichés.
changing the subject.
giving false reassurance.
The Correct Answer is C
A. Judgmental response.
This isn’t necessarily judgmental, as it doesn't express an opinion about the patient’s feelings or concern.
B. Using clichés.
Clichés are general or overused phrases meant to provide comfort but are not present here.
C. Changing the subject.
Changing the subject dismisses the patient's concern without acknowledging it, which is evident here as the nurse diverts to breakfast without addressing the worry.
D. Giving false reassurance.
False reassurance involves saying something unrealistic to make the patient feel better, which isn't directly done here.
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Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
Correct Answer is C
Explanation
A. wrings her hands and paces around the room while denying that she is upset.
This example reflects incongruence. The patient's body language (pacing, wringing hands) suggests anxiety or distress, which does not match her verbal denial of being upset.
B. states she is comfortable while she frowns, and her teeth are clenched.
This example also reflects incongruence. Her facial expression and clenched teeth contradict her statement of comfort, indicating her communication is not aligned.
C. is tearful and slow in speech when talking about her husband's death.
This example reflects congruence. The patient’s verbal expression and nonverbal cues are aligned, indicating that her communication is consistent with her emotions.
D. smiles and laughs while speaking of feeling lonely and depressed.
This example reflects incongruence. Smiling and laughing contradict the verbal expression of loneliness and depression, indicating a mismatch in her communication.