The nurse is assessing a patient with chest pain who has just come to the hospital.
Which open-ended query will provide the nurse with helpful information about the patient's health status?

Choice A rationale

Determining the client's goals and expectations regarding hospitalization is crucial for patient-centered care. Understanding what the client hopes to achieve during their stay allows the nurse to tailor the care plan to meet their individual needs and preferences, promoting adherence and satisfaction.

Choice B rationale

Establishing a therapeutic relationship with the client and their wife is fundamental for effective communication and trust. A strong rapport facilitates open dialogue, allowing the nurse to gather accurate information, provide emotional support, and involve the family in the care process.

Choice C rationale

Identifying the client's chief complaints, concerns, and worries is the primary focus of the initial interview. Understanding the main reasons for seeking healthcare helps the nurse to prioritize assessments and interventions, addressing the most pressing issues first.

Choice D rationale

Ascertaining which parts of the interview may require further exploration guides subsequent data collection. Identifying areas where more detailed information is needed ensures a comprehensive understanding of the client's health status and allows the nurse to focus on relevant aspects in follow-up interactions.

Choice E rationale

While reviewing the client's past medical history is important, it is usually a more detailed process that occurs after the initial interview to identify immediate concerns. The initial interview focuses on the present situation and the client's current perspective.

Choice A rationale

While nursing regulations do outline standards of care, the primary rationale for frequent repositioning and padding is not solely based on delegation limitations. Preventing pressure injuries is a fundamental nursing responsibility, regardless of who performs the tasks under appropriate supervision.

Choice B rationale

Identifying patient care areas needing additional assistance is a separate aspect of nursing assessment and care planning. While repositioning and padding contribute to overall well-being, their direct rationale is the prevention of skin breakdown, not the identification of staffing needs.

Choice C rationale

Unconscious patients are at high risk for developing pressure injuries due to immobility and decreased sensation. Repositioning at least every two hours reduces prolonged pressure on bony prominences, and padding distributes pressure more evenly, both crucial interventions in preventing tissue ischemia and subsequent ulcer formation.

Choice D rationale

While standing orders may include guidelines for repositioning and skin care, the underlying rationale stems from the physiological need to prevent pressure injuries in immobile patients. The nurse's actions are based on established principles of preventing complications associated with immobility, not solely on following pre-written orders. .