The nurse has entered a client's room after receiving a morning report. The nurse rapidly assessed the client's airway, breathing, and circulation and greeted the client by saying "Good morning." The client has made no reciprocal response to the
A) The nurse should ask appropriate questions to understand the reasons for the client's silence.
B) The nurse should apologize for bothering the client, perform necessary assessments efficiently and leave the room.
C) The nurse should document the client's withdrawal and diminished mood in the nurse's notes.
D) The nurse should ask the client if he feels afraid or angry.
Ans: A
Silence can have many meanings, and the nurse should attempt to identify the meaning of the client's silence in a tactful manner. Directly asking if the client is angry or fearful is likely presumptuous and may harm rapport. The nurse should not make assumptions around the client's mood nor should the nurse cease to engage with the client.
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