The nurse would identify an opportunity for a “teaching moment” in the situation of a patient who:
is packing belongings in preparation for discharge.
says, "How will I remember all the things about my new diet?"
has just returned from surgery for a deviated septum.
has just been told of the malignancy of his tumor.
The Correct Answer is B
A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.
B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.
C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.
D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.
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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.
Correct Answer is C
Explanation
A. "Come and get me if Mr. Jones has a high heart rate." This statement lacks specificity, as “high heart rate” is vague. The assistant may not know what range constitutes “high.”
B. "I need to know if Mr. Jones' blood pressure is elevated."
This statement is also too vague, as the assistant may not understand what is considered "elevated."
C. "If Mr. Jones' heart rate is greater than 100, let me know."
This direction is clear and specific, providing a measurable parameter for the assistant to follow, making it the best option.
D. "Let me know if Mr. Jones' temperature is high."
"High" is vague, as it does not provide a specific value or range for temperature.