A nurse is caring for an older adult client who is recovering from surgery. During the nurse's assessment, the client appears withdrawn, avoids eye contact, and repeatedly rubs their hands together. What is the most appropriate initial action for the nurse to take based on these observations?
Use therapeutic communication to encourage the client to share their feelings.
Provide reassuring physical contact, such as holding the client's hand, to calm them.
Ask the client about their level of pain and offer to adjust their medication if necessary.
Document the observed behaviors in the client's chart for the healthcare team to review later.
The correct answer is to use therapeutic communication to explore the client's feelings. Non-verbal cues such as withdrawal, avoidance of eye contact, and fidgeting often indicate emotional distress or anxiety. Therapeutic communication techniques, including open-ended questions or statements that encourage expression, help the client verbalize concerns. Touching the client without first assessing emotional status can heighten discomfort. Simply documenting the behavior without intervening misses the opportunity to relieve distress. Asking about pain is important, but the cues in this scenario are more suggestive of psychological stress than physical pain, so therapeutic communication is the priority.
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Psychosocial Integrity
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