Upon entering the room, the client is found crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?

Question

1. Implementing nursing intervention
2. Determining the nurse's need for assistance
3. Supervising delegated care
4. Reassessing the client

Answer 1

Correct Answer: 4
Rationale 1: In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience and so the planned intervention should not be initiated.
Rationale 2: In this situation, the nurse does not need assistance.
Rationale 3: This is not a situation where the nurse must supervise care that has been delegated.
Rationale 4: Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed or to discover if there are new data that indicate a need to change the priorities of care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the situation and implements a more appropriate intervention. In this situation, the nurse does not need assistance, nor is this a situation where the nurse must supervise care that has been delegated.