A nurse is caring for a client in an outpatient clinic.

Exhibits

Complete the following sentence by using the lists of options. The client is at highest risk for developing

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evidenced by the client's

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A. Move the client to a table where other clients are playing cards. A client exhibiting signs of anxiety, such as pacing and hand-wringing, may find social interactions overwhelming. Forcing engagement in a group activity could increase distress rather than provide comfort.
B. Ask the client if they would like to watch television. Television may not be helpful for an anxious client, as it can add to sensory overload rather than provide a calming effect. A more effective approach is direct communication and grounding techniques.
C. Use short, simple sentences when speaking with the client. Anxiety can impair concentration and comprehension. Speaking in short, clear sentences helps the client process information more easily and can promote a sense of security. Calm, concise communication is essential in de-escalating anxiety.
D. Allow the client to have 1 hr of time alone in their room. While some clients may benefit from time alone, extended isolation is not an appropriate first intervention. It is more effective to provide support and reassurance through clear communication before considering a break in a quiet environment.

A. Place a pulse oximeter on the client's finger. While assessing oxygen saturation is important, it is not the priority in this situation. The client is cyanotic with a respiratory rate of 8/min and shallow respirations, indicating severe respiratory compromise. Immediate intervention is needed before assessing oxygen saturation.
B. Administer oxygen to the client. Providing oxygen is appropriate, but it will not be effective if the client's airway is obstructed or if their respirations are inadequate. Oxygen delivery is only useful when there is a patent airway and effective ventilation.
C. Check the client's pulse rate. Assessing circulation is important, but the priority in this situation is ensuring an open airway to allow for adequate oxygenation. The client's respiratory status suggests that they may not be effectively exchanging oxygen, which must be addressed immediately.
D. Establish a patent airway for the client. The priority action is to ensure a patent airway, as compromised respirations can lead to respiratory failure and cardiac arrest. Airway management, such as repositioning the head, using airway adjuncts, or preparing for assisted ventilation, takes precedence over other interventions to ensure oxygen delivery.