A nurse realizes they made an incorrect entry in a patient’s medication administration record. What is the appropriate action for the nurse to take?

Choice A rationale
Sitting quietly and engaging the client can be supportive, but it may not be sufficient to establish rapport. While presence is important, it lacks the active engagement and therapeutic techniques needed to build a connection.
Choice B rationale
Using open-ended questions starting with “I want time to think and reflect” is not appropriate in this context. Open-ended questions are useful, but the phrasing here is not conducive to therapeutic communication and may confuse the client.
Choice C rationale
Using therapeutic communication techniques is the correct approach. These techniques include active listening, empathy, and validation, which are essential for building rapport and trust with the client. They help the client feel understood and supported.
Choice D rationale
Offering tissues and a comforting presence is supportive but not sufficient on its own. While it shows empathy, it does not actively engage the client in a therapeutic manner to establish rapport.

Choice A rationale
On initial evaluation by the home health nurse, a comprehensive assessment is typically performed to gather baseline data. This initial assessment is thorough and includes a detailed history and physical examination to understand the patient’s overall health status. It is not a partial ongoing assessment, which is more focused and conducted after the initial comprehensive assessment to monitor specific issues or changes in the patient’s condition.
Choice B rationale
Reassessing a client for pain after giving pain medication is an example of a partial ongoing assessment. This type of assessment is focused on evaluating the effectiveness of an intervention, such as pain medication, and determining if further action is needed. It involves collecting specific data related to the patient’s pain levels and response to treatment, rather than a comprehensive evaluation of their overall health.
Choice C rationale
Checking skin assessment on a patient with a medical device in place is also an example of a partial ongoing assessment. This focused assessment is conducted to monitor the condition of the skin around the medical device, looking for signs of pressure ulcers, infection, or other complications. It is not a comprehensive assessment but rather a targeted evaluation of a specific area of concern.

Choice D rationale
Preparing the client for discharge involves a comprehensive assessment to ensure that the patient is ready to leave the healthcare facility and can manage their care at home. This assessment includes evaluating the patient’s physical, psychological, and social needs, as well as their ability to perform activities of daily living. It is not a partial ongoing assessment, which is more focused and conducted during the course of care to monitor specific issues.