Which set of vital signs, taken on an adult, is cause for concern and requires further evaluation?

Remaining attentive but silent is an appropriate response by the nurse.

This allows the client to express their feelings and concerns without interruption or judgment.

It also shows the client that the nurse is actively listening and interested in what they have to say.

Choice A is not an appropriate response because placing a client on a 72-hour hold should only be done if the client is a danger to themselves or others.

Choice C is not an appropriate response because leaving the room immediately would be unprofessional and could make the client feel abandoned.

Choice D is not an appropriate response because telling the client that everything will be fine may not be true and could give false hope.

“Do you know how to change your dressing?” This statement can create a barrier to communication because it may make the patient feel judged or defensive if they do not know how to change their dressing.

It is better to phrase the question in a more open-ended and non-judgmental way, such as “Can you tell me about your experience with changing your dressing?”

Choice B is not an answer because it encourages the patient to share information about their hospitalization and promotes open communication.

Choice C is not an answer because it shows that the speaker is actively listening and engaging with the patient’s previous statements.

Choice D is not an answer because it encourages the patient to share information about their pain management and promotes open communication.