A nurse in an emergency department is caring for a client who is unconscious and requires surgery. There is no one available to give consent for the treatment. Which of the following actions should the nurse take?

A. "We can discuss what you can expect during your stay."

This statement acknowledges the client's feelings of anxiety and offers support by indicating a willingness to discuss what they can expect during their stay. Providing information about the facility's routines, procedures, and what to expect can help alleviate anxiety by giving the client a sense of control and understanding. It also opens the door for the client to ask questions and express any concerns they may have.

B. "Most people are scared their first time in a health care facility":

While this statement attempts to normalize the client's feelings by suggesting that it is common to feel scared, it may not effectively address the client's individual concerns or provide reassurance. Additionally, some clients may not find comfort in knowing that others are also scared.

C. "You have nothing to worry about. Everything will be fine":

This statement may come across as dismissive of the client's feelings and does not acknowledge or validate their anxiety. It also makes assumptions about the client's experience and may not be accurate for all clients. Providing blanket reassurances without addressing the client's specific concerns may not be effective in alleviating their anxiety.

D. "Why are you feeling scared about being in this facility?":

While it is important for the nurse to explore the client's feelings and concerns, asking a direct question like this may put pressure on the client to articulate their anxiety without offering immediate support or reassurance. It is better to provide a statement that offers support and opens the door for the client to express their concerns in their own time and comfort level.

A. "I will remove my antiembolic stockings while I am in bed": Antiembolic stockings, also known as compression stockings, are worn to prevent deep vein thrombosis (DVT) by promoting venous return. Removing them while in bed would compromise their effectiveness in preventing blood clots.

B. "I will perform ankle and knee exercises every hour."

Performing ankle and knee exercises every hour helps prevent complications such as muscle atrophy, contractures, and thromboembolism associated with immobility. These exercises promote circulation, maintain joint mobility, and prevent stiffness.

C. "I will hold my breath when rising from a sitting position": Holding one's breath while rising from a sitting position can increase intra-abdominal pressure and potentially cause dizziness or fainting. It is not a recommended practice and may lead to orthostatic hypotension.

D. "I will have my partner help me change positions every 4 hours": Changing positions every 4 hours is important for preventing pressure ulcers and promoting comfort, but it may not be frequent enough to prevent other adverse effects of immobility, such as joint stiffness and muscle weakness. Frequent position changes, at least every 2 hours, are recommended to maintain circulation and prevent complications.