A nurse is working in a burn center that provides care for patients with severe burn injuries. Which of the following interventions is an example of tertiary prevention?

Rationale:

A. Provide detailed observations of the client's facial expressions is incorrect because while noting nonverbal cues can be helpful, facial expressions are objective observations, not the client’s subjective experience. Subjective data should reflect the client’s own report.

B. Document the client's statements in direct quotes is correct because subjective data represents the patient’s personal experience, symptoms, or feelings. Using direct quotes preserves the patient’s own words, ensuring accuracy and avoiding misinterpretation by the nurse. This method clearly differentiates subjective data from objective findings in the medical record.

C. Avoid documenting subjective data unless supported by objective findings is incorrect because subjective data is valid and essential in the nursing assessment, even if it cannot be objectively measured. Ignoring the patient’s report could compromise care planning and patient-centered practice.

D. Summarize the client's symptoms using medical terms is incorrect because paraphrasing may inadvertently alter the meaning or intensity of the patient’s experience. Direct quotes are preferred to maintain the integrity of the patient’s subjective report.

Rationale:

A. Maintaining neutral facial expressions and making occasional encouraging comments is correct because active listening involves giving the client full attention, demonstrating empathy, and providing nonverbal and verbal cues that encourage continued sharing. Techniques include eye contact, nodding, and brief affirmations like “I see” or “Go on,” which validate the client’s feelings and promote effective communication.

B. Writing down every word the client says without making eye contact is incorrect because while documentation is important, focusing entirely on note-taking can make the client feel ignored and hinder rapport. Active listening requires engagement and responsiveness, not just recording information.

C. Interrupting the client to clarify details immediately is incorrect because frequent interruptions can disrupt the client’s narrative and reduce trust. Active listening prioritizes understanding the client’s perspective before seeking clarification.

D. Planning the next question while the client is speaking is incorrect because it divides the nurse’s attention and can prevent full comprehension of the client’s concerns. Active listening requires focusing on the client’s words and emotions in the moment, not preemptively preparing responses.