A nurse is assessing an infant during a routine health examination. The nurse notes that the infant's anterior fontanel is sunken. How should the nurse interpret this finding?

Rationale:

A. Open-ended questions are designed to encourage the client to provide detailed, descriptive responses rather than simple yes/no or one-word answers. This helps the nurse gain a deeper understanding of the client’s health status, concerns, and experiences.

B. This is characteristic of closed-ended questions, not open-ended questions. Closed-ended questions limit the client’s response to brief, factual answers and do not provide the same depth of information.

C. Open-ended questions are intended to elicit detailed and narrative responses, not just simple or direct answers. Therefore, this statement is inaccurate.

D. Open-ended questions give clients the opportunity to express their priorities, feelings, and concerns, which may reveal important information that might not be captured through structured or closed-ended questions.

E. By allowing clients to speak freely and feel heard, open-ended questions foster trust and a therapeutic nurse-client relationship. This promotes effective communication and client engagement.

Rationale:

A. Asking the client to cough every 4 hours is insufficient in response to hypoxemia. Frequent coughing may help clear secretions, but it does not directly improve oxygen saturation and waiting several hours between coughs may delay intervention.

B. Requesting a prescription for an opioid analgesic is not appropriate because opioids can depress respiratory drive, which may worsen hypoxemia. Administering an opioid without respiratory assessment could be dangerous for a client with low oxygen saturation.

C. Encouraging the client to take deep breaths is correct. Deep breathing exercises, including techniques such as incentive spirometry, help expand the lungs, improve alveolar ventilation, and increase oxygenation. This intervention is noninvasive, safe, and directly addresses the low oxygen saturation.

D. Decreasing the head of the bed is incorrect. A supine or flat position can reduce lung expansion and worsen oxygenation. Elevating the head of the bed, or having the client sit upright, promotes better lung expansion and improves oxygen saturation.