A nurse in a primary care provider’s office is caring for a client.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Nurses’ Notes

Today, 0900: Client returns for a follow-up examination after new onset of symptoms; client reports loss of appetite; reports sleeping most of the day; became teary when asked about plans for activities; questions reason to live if not working; auscultated lungs for a dry, nonproductive cough; breath sounds present bilaterally; experiences occasional muscle “aches and pains”; reports having no energy.

Choice A reason:
The statement "Speak to the client in a loud voice" is not appropriate. Speaking loudly can escalate the client's agitation and increase their distress. It is important to use a calm, gentle tone to help de-escalate the situation.

Choice B reason:
The statement "Identify the client's stressors" is the correct response. Understanding what is causing the client's agitation can help in addressing the root cause and calming the client. Identifying stressors is a key step in managing agitation effectively.

Choice C reason:
The statement "Stand directly in front of the client" is not advisable. Standing directly in front of an agitated client can be perceived as confrontational and may increase their agitation. It is better to stand at an angle or to the side to avoid appearing threatening.

Choice D reason:
The statement "Talk to the client using short, simple sentences" is the correct response. Using clear, concise language helps the client understand instructions and reduces confusion, which can help in calming them down.

Choice E reason:
The statement "Request that security guards restrain the client" is not appropriate as a first response. Restraints should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.

Choice A Reason:
Using short, simple sentences is an effective communication strategy for clients experiencing moderate anxiety. Anxiety can impair cognitive processing, making it difficult for clients to understand complex information. By using clear and concise language, the nurse can help the client better comprehend what to expect after the cardiac catheterization. This approach reduces the client's anxiety by providing information in a manageable format.

Choice B Reason:
Showing a 30-minute teaching video might be overwhelming for a client with moderate anxiety. While visual aids can be helpful, the length and complexity of the video could increase the client's anxiety rather than alleviate it. It is important to tailor the educational approach to the client's current emotional state, ensuring that the information is presented in a way that is easy to understand and not overwhelming.

Choice C Reason:
Providing detailed explanations can be counterproductive for a client with moderate anxiety. Detailed information might overwhelm the client, leading to increased anxiety and difficulty in processing the information. Instead, the nurse should focus on delivering key points in a clear and concise manner, ensuring that the client understands the most important aspects of the procedure and what to expect afterward.

Choice D Reason:
Avoiding questions is not an effective strategy for client education. Asking questions allows the nurse to assess the client's understanding and address any concerns or misconceptions. Engaging the client in a dialogue helps to build rapport and ensures that the client feels supported and informed. It is important to create an open and interactive environment where the client feels comfortable asking questions and expressing concerns.