The nurse is caring for an acutely ill client. Which assessment finding should prompt the nurse to inform the healthcare provider that the client may be exhibiting signs of acute kidney injury (AKI)?

Choice A reason: Saying “I am not sure I follow you” seeks clarification, encouraging the patient to elaborate without dismissing their feelings. It fosters open communication, allowing the nurse to understand the patient’s concerns better, which supports therapeutic interaction and validates the patient’s emotional expression in a clinical setting.

Choice B reason: Noticing lip-biting acknowledges nonverbal cues, signaling the nurse’s attentiveness to the patient’s emotional state. This observation invites further discussion without judgment, promoting trust and validating the patient’s feelings, which is therapeutic and does not undermine or belittle their concerns in a mental health context.

Choice C reason: Stating “You appear tense” reflects observation of the patient’s emotional state, prompting exploration of underlying issues. It validates the patient’s feelings without dismissal, encouraging dialogue. This therapeutic approach supports emotional expression and does not belittle concerns, making it appropriate in a nurse-patient interaction.

Choice D reason: Saying “Everything will be alright” dismisses the patient’s concerns by offering false reassurance without addressing specific issues. This minimizes their emotional experience, potentially invalidating feelings and discouraging open communication, which can undermine trust and hinder therapeutic progress in managing mental health concerns.

Choice A reason: Assault involves threatening harm, not applicable here, as the issue is failure to document assessments, not intentional threats by staff. The client’s self-harm resulted from inadequate monitoring, not a staff-initiated threat, making assault an incorrect legal issue in this scenario.

Choice B reason: Battery involves unauthorized physical contact, not relevant to failure to document assessments. The client’s self-harm stemmed from inadequate observation, not staff-inflicted harm, making battery an inappropriate legal claim compared to negligence in monitoring and documentation.

Choice C reason: Suicide risk is a clinical concern, not a legal issue to defend against. While the client’s self-harm indicates risk, the hospital’s liability arises from failure to follow monitoring protocols, not the risk itself, making this option incorrect for the legal defense context.

Choice D reason: Malpractice involves negligence, such as failing to document hourly assessments for a high-risk client, leading to harm. This breach of standard care (1:1 observation) allowed self-harm, making the hospital liable for not adhering to protocols, requiring defense against malpractice for inadequate monitoring and documentation.