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 C
Explanation
The correct answer is choice C. Taking a hot shower in the morning can help decrease stiffness and improve joint mobility for people with rheumatoid arthritis. This is one of the self-management strategies that can reduce pain and disability.
Choice A is wrong because applying cold packs directly on the skin of the affected joints can cause vasoconstriction and increase inflammation.
Cold therapy should be used with caution and with a barrier between the skin and the ice pack.
Choice B is wrong because biological response modifiers are not used to prevent infection, but to reduce inflammation and slow down joint damage in rheumatoid arthritis.
These medications can actually increase the risk of infection by suppressing the immune system.
Choice D is wrong because clustering physical activities during the day can cause fatigue and joint stress for people with rheumatoid arthritis.
It is better to pace activities throughout the day and take frequent breaks to rest the joints.
Normal ranges for rheumatoid arthritis are based on the disease activity score (DAS), which measures the number of swollen and tender joints, the level of inflammation in the blood, and the patient’s global assessment of health. A DAS below 2.6 indicates remission, a DAS between 2.6 and 3.2 indicates low disease activity, a DAS between 3.2 and 5.1 indicates moderate disease activity, and a DAS above 5.1 indicates high disease activity.
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.
This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.
Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.
Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.
Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.
Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.
In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.
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