A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
Assess the cause of the agitation.
Reassure the client that he or she is safe.
Restrain the client's hands.
Sedate the client immediately.
The Correct Answer is A
A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.
B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.
C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.
D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Controlling my blood pressure will decrease my risk of having a heart attack to some degree." This statement is accurate. Controlling blood pressure reduces the risk of developing ACS.
B. "Because I'm over 80, even a 20 mm Hg drop in my blood pressure can reduce my risk." Research indicates that even modest reductions in blood pressure can significantly lower the risk of cardiovascular events, especially in older adults.
C. "High blood pressure will increase my body's need for oxygen and increase my heart's workload." High blood pressure increases myocardial oxygen demand and can lead to ischemia, which is a precursor to ACS.
D. "My high blood pressure has no relationship to the severity of heart disease or its outcomes." This statement is false. High blood pressure is a major risk factor for heart disease, including ACS, and it directly affects the severity and outcomes of heart disease.
Correct Answer is ["A","D"]
Explanation
A. HAV: Hepatitis A is spread via the fecal-oral route, often through contaminated food or water.
B. HCV: Hepatitis C is primarily spread through blood-to-blood contact, not the fecal-oral route.
C. HDV: Hepatitis D is spread through blood contact and requires Hepatitis B for replication.
D. HEV: Hepatitis E is spread through the fecal-oral route, similar to Hepatitis A.
E. HBV: Hepatitis B is spread through blood, sexual contact, and perinatal transmission, not the fecal-oral route.
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