In the immunization clinic, the nurse notices a client displaying tense body posture. Which of the following is the most therapeutic response for the nurse to make?
1. "This won't hurt a bit."
2. "You need to relax."
3. "I can tell you've had a bad experience before."
4. "I notice you are clenching your fists."
4
Rationale: The nurse's observation about clenched fists is a therapeutic intervention, which conveys the nurse is attending to the nonverbal cues of the client. Making an assumption that the client has had a bad experience before is not therapeutic. Telling the client that the immunization will not hurt is offering false reassurance. Directing the client to relax is a form of giving advice, which is not therapeutic.
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