Which of the following actions are part of the nursing process? (Select all that apply.)

Introduction:

Therapeutic verbal communication serves as the foundation for building a trusting nurse-patient relationship and ensuring patient understanding. Effective communication involves clarity, empathy, and the active exchange of information to facilitate comprehensive care, minimize anxiety, and promote patient compliance with medical recommendations and prescribed treatment regimens.

A. Medical jargon often creates a barrier to understanding, especially for patients without a clinical background. Using technical terminology can lead to confusion, anxiety, and misunderstanding of medical instructions, which compromises patient safety and the effectiveness of the nurse’s patient education efforts during the clinical interview or procedure explanation.

B. While accurate documentation is critical for medical records and legal purposes, it is a written communication skill rather than an example of verbal interaction. Verbal communication specifically refers to the spoken exchange of information between individuals, such as the nurse, the patient, and the members of the healthcare team.

C. Clear, simple language combined with active listening ensures that the patient comprehends the information shared and feels validated. By tailoring communication to the patient's level of understanding, the nurse creates a collaborative environment, increases patient satisfaction, and significantly improves the quality of care provided during clinical encounters.

D. Delegating tasks is a management strategy, not a form of verbal communication. Furthermore, the motivation to "avoid completing it personally" is an inappropriate rationale for delegation. Delegation should be based on the scope of practice, patient safety, and the optimization of care, never on a desire to avoid responsibilities.

Introduction:

Effective risk management involves implementing safety protocols aimed at mitigating potential patient injury. Nurses must proactively identify hazards to maintain a secure environment and reduce the incidence of preventable adverse events.

A. Placing all four side rails up is generally considered a form of restraint, which requires specific physician orders and frequent monitoring. Routinely using four rails can increase the risk of injury if a patient attempts to climb over them, making this action counterproductive to safety.

B. Educating the patient on how to use the call light is a fundamental safety intervention. This ensures that the patient can request assistance promptly, thereby reducing fall risk by preventing the patient from attempting to get out of bed independently without proper clinical supervision or assistance.

C. Applying a bed alarm is a critical proactive measure used to monitor patients who are at a high risk for falling. It alerts nursing staff immediately when a patient attempts to exit the bed, allowing for rapid intervention and prevention of falls before the patient can ambulate unassisted.

D. Keeping the bed in the lowest position is a standard safety practice that significantly reduces the distance a patient would fall if they were to roll out of bed. This simple, effective environmental modification is a foundational preventive strategy utilized in all clinical settings to ensure patient safety.

E. Removing all assistive devices is an unsafe practice that inhibits patient mobility and independence. Assistive devices like walkers or canes are necessary for patients with impaired gait; removing them increases the likelihood of a patient attempting to ambulate without necessary support, thereby increasing the overall fall risk.