A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
Engage the panic alarm
Use a face shield with a mask when providing care to the client.
Tell the client, “You seem to be very upset.”
Initiate seclusion protocol.
The Correct Answer is C
Tell the client, “You seem to be very upset.”.
This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer and explanation.
The correct answer is choice D. Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficit.
Choice A is wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
Choice B is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
Choice C is wrong because obesity is not a contraindication for acupuncture.
Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones.
Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively.
Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L.
Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.
Correct Answer is C
Explanation
The correct answer is choice C. Provide anticipatory guidance classes to parents through public schools. This is because anticipatory guidance is a type of health teaching that involves sharing information and experiences through educational activities designed to improve health knowledge, attitudes, behaviors, and skills. Anticipatory guidance helps parents to prevent or reduce health problems in their children by providing them with information on topics such as nutrition, immunization, injury prevention, and developmental milestones. Providing anticipatory guidance classes through public schools is an example of a population-based public health intervention that aims to improve the health of a large group of people who share common characteristics or risks.
Choice A is wrong because tertiary health interventions are not the best way to improve health for the local population. Tertiary health interventions are those that focus on treating and rehabilitating people who have already developed a disease or disability. They are more costly and less effective than primary or secondary health interventions, which aim to prevent or detect diseases early.
Encouraging rural residents to focus health spending on tertiary health interventions would not address the underlying causes of poor health in the community.
Choice B is wrong because having a nurse from outside the community provide health lectures at the county hospital is not a culturally appropriate or accessible way to deliver health education. A nurse from outside the community may not understand the needs, values, beliefs, and practices of the rural residents, and may not be able to establish trust and rapport with them. Moreover, the county hospital may not be a convenient or comfortable location for many rural residents to attend health lectures, especially if they have transportation, financial, or time barriers.
A better approach would be to involve local community members and leaders in planning and delivering health education programs that are tailored to the rural context and culture.
Choice D is wrong because launching a media campaign to increase awareness about industrial pollution is not a sufficient action to improve health for the local population. While increasing awareness is an important first step, it does not necessarily lead to behavior change or environmental improvement.
A media campaign alone would not address the sources and effects of industrial pollution, nor would it provide solutions or resources for the rural residents to protect themselves from exposure.
A more comprehensive action would be to collaborate with other stakeholders, such as environmental agencies, industry representatives, and community groups, to develop and implement strategies for reducing and monitoring industrial pollution and its impact
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