A nurse is getting a client out of bed to ambulate for the first time.

The client is pale, diaphoretic, has a pulse of 100/minute, and says, “I feel weak.

Let me sit on the side of the bed for a minute.” What finding should the nurse document?

What has it been like for you since your wife died? This statement shows empathy and invites the client to share his feelings and experiences.

It also acknowledges the client’s loss and validates his grief.

Choice A. Tell me how your wife died.

This statement is too intrusive and may cause the client to feel uncomfortable or defensive. It also focuses on the past event rather than the present situation.

Choice B. Have you considered attending a grief group? This statement is too premature and may imply that the nurse is trying to solve the client’s problem or dismiss his feelings.

It also assumes that the client needs or wants a grief group.

Choice D. You have wonderful children and grandchildren who are very supportive.

This statement is too superficial and may minimize the client’s grief or make him feel guilty. It also shifts the attention away from the client and his wife.

Inspection, palpation, percussion, and auscultation are the four techniques used to perform a physical assessment.

Inspection involves observing the patient’s appearance, posture, movement, and behavior. Palpation involves feeling the patient’s skin, organs and pulses with the hands.

Percussion involves tapping the patient’s body with the fingers or a small hammer to elicit sounds or vibrations.

Auscultation involves listening to the patient’s heart, lungs, and bowel sounds with a stethoscope.

Choice A is wrong because relationship and evaluation are not techniques of physical assessment.

Relationship refers to the rapport and trust established between the nurse and the patient.

Evaluation refers to the process of comparing the expected outcomes with the actual outcomes of the nursing interventions.

Choice C is wrong because vital signs, health history, general survey, and height and weight are not techniques of physical assessment.

They are components of a health assessment, which is a broader term that includes physical assessment as well as other aspects of the patient’s health status.

Choice D is wrong because color is not a technique of physical assessment.

Color is an aspect of inspection, which is one of the techniques of physical assessment.