Upon entering a room, a client and spouse are found crying. The nurse decides to sit with both of them, offering presence and listening to their fears instead of providing the planned education. What action did the nurse perform?
1. Implementing nursing intervention
2. Determining the nurse's need for assistance
3. Supervising delegated care
4. Reassessing the client
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.
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