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?

This is because the nurse’s reply does not address the client’s fear of radiation therapy, but rather provides factual information that may not be relevant or helpful to the client.

The nurse is not using a therapeutic communication technique, such as reflecting, exploring, or validating the client’s feelings.

Instead, the nurse is shutting down the communication and missing an opportunity to learn more about the client’s concerns and needs.

Choice A is wrong because the nurse is not confronting a painful subject, but rather avoiding it.

The nurse is not acknowledging the client’s fear or inviting the client to talk more about it.

Choice C is wrong because the nurse is not recognizing that the client needs information, but rather assuming that the client does.

The nurse is not asking the client what he or she wants to know about radiation therapy, but rather telling the client what he or she should know.

Choice D is wrong because the nurse is not perceiving that the client is ready to hear more about the treatment, but rather imposing information on the client.

The nurse is not assessing the client’s readiness to learn, but rather giving unsolicited advice.

This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.

Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.

Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.

Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.

Normal ranges for vital signs are as follows :

• Blood pressure: 90/60 mm Hg to 120/80 mm Hg
• Breathing: 12 to 18 breaths per minute
• Pulse: 60 to 100 beats per minute
• Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)