A nurse is providing care to a client who is preparing to undergo surgery. The client inquires about advance directives. Which of the following statements should the nurse make?

Choice A reason: Pointing toes eases stocking application, reducing drag on skin. Scientifically, this aligns with proper technique, enhancing venous return without resistance, so no intervention is needed, as it supports effective antiembolic function per guidelines.

Choice B reason: Creases on the front risk pressure sores or impaired circulation, countering antiembolic goals. Scientifically, smooth application prevents venous stasis, requiring intervention, as this error compromises blood flow and skin integrity in at-risk clients.

Choice C reason: Turning stockings inside out aids application, a standard technique for even fit. Scientifically, this ensures proper compression gradient, supporting venous return, so no intervention is warranted, as it’s correct per procedural evidence.

Choice D reason: Applying before getting out of bed maximizes compression benefits, reducing clot risk. Scientifically, this aligns with prophylaxis timing, as gravity aids swelling post-ambulation, making it appropriate and not requiring nurse intervention.

Choice A reason: Seclusion is a last resort, not first, per de-escalation principles. It risks escalating agitation or trauma without addressing the cause. Scientifically, verbal intervention precedes restraint, as identifying triggers can calm the client, aligning with evidence-based psychiatric care prioritizing least restrictive measures.

Choice B reason: Assisting with needs is vague and secondary to identifying the agitation’s source. Without understanding the trigger, this lacks focus. Scientifically, pinpointing the upset first guides effective support, making this a follow-up, not initial, step in managing acute behavioral distress.

Choice C reason: Asking what upset the client de-escalates by engaging them, identifying triggers for targeted intervention. This aligns with scientific psychiatric practice, reducing agitation through communication before medication or seclusion, addressing the root cause effectively as the first step in evidence-based care.

Choice D reason: Administering lorazepam IM is premature without de-escalation attempts. It risks over-sedation or side effects, bypassing verbal strategies. Scientifically, medication follows failed non-pharmacological efforts per guidelines, making this a later option, not the first, in managing agitation safely and effectively.