During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her.
She wants to get more information.
Which ask is most appropriate to help Crystal in her assessment? (Case #2)

Choice A rationale

The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.

Choice B rationale

The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.

Choice C rationale

The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.

Choice D rationale

Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.

Choice A rationale

Nausea and vomiting after narcotic pain medication, while uncomfortable, are often expected side effects. The nurse should address these symptoms with antiemetics or other comfort measures, but this is generally not the highest priority unless the vomiting is severe or leads to dehydration or electrolyte imbalance.

Choice B rationale

A constipated patient needing to use the toilet should be assisted promptly for comfort and to prevent further complications. However, this need is generally not life-threatening and can usually be addressed after more urgent issues.

Choice C rationale

A patient waiting for discharge teaching is important, but discharge planning can typically be done once the patient is stable and other immediate needs are addressed. While timely discharge is a goal, it is not the priority when a patient is experiencing acute distress.

Choice D rationale

Chest pain and shortness of breath after nitroglycerin administration are signs of potential serious cardiovascular or respiratory compromise. Nitroglycerin should relieve chest pain; if it persists or worsens with shortness of breath, it could indicate worsening angina, myocardial infarction, or an adverse reaction to the medication. This situation requires immediate assessment and intervention as it poses an immediate threat to the patient's well-being.