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
Choice A option
Fibrinogen level: Fibrinogen is a protein involved in the blood clotting process, but in this case, it is not appropriate because is not the primary laboratory test used to monitor warfarin therapy. Monitoring fibrinogen levels is more relevant in assessing bleeding disorders or certain medical conditions.
Choice B option
PTT (Partial Thromboplastin Time): PTT is another laboratory test used to evaluate blood clotting function, particularly the intrinsic pathway of the clotting cascade. PTT is not routinely used to monitor warfarin therapy; it is more commonly used to monitor other anticoagulant medications like heparin.
Choice C option
The nurse should plan to report the client's INR (International Normalized Ratio) to obtain a prescription for the client's daily warfarin. INR is a critical laboratory test used to monitor the effectiveness and safety of warfarin therapy.
Warfarin is an anticoagulant medication commonly prescribed to prevent and treat blood clots. It works by interfering with the body's ability to use vitamin K to form blood clots. Monitoring the INR is essential because it indicates how long it takes for the blood to clot, and it helps determine if the client's warfarin dosage needs adjustment to achieve the desired level of anticoagulation.
Choice D option
Platelet count: Platelet count is essential to assess the number of platelets in the blood, which are crucial for normal clotting. However, platelet count monitoring is not the primary focus when prescribing warfarin. It is typically used to evaluate thrombocytopenia (low platelet count) or other conditions affecting platelet function.
Correct Answer is D
Explanation
I will need to keep my hand elevated above my heart for several days.” This statement indicates that the client understands the importance of reducing swelling and inflammation in the affected hand after carpal tunnel surgery.
Elevation promotes venous return and prevents fluid accumulation in the tissues.
Choice A is wrong because applying heat for the first 24 hours can increase blood flow and swelling in the hand, which can cause more pain and delay healing. Ice packs are recommended for the first 24 to 48 hours to reduce inflammation.
Choice B is wrong because the client should not avoid using the affected hand for 4 to 6 weeks, as this can lead to stiffness, muscle atrophy, and decreased range of motion. The client should move the fingers periodically and perform gentle exercises as prescribed by the surgeon or physical therapist.
Choice C is wrong because numbness and tingling in the hand are signs of nerve compression, which is the main cause of carpal tunnel syndrome.
The client should expect these symptoms to improve or resolve after surgery, not persist or worsen. If the client experiences numbness and tingling after surgery, they should report it to the surgeon as it may indicate a complication such as nerve injury or hematoma.
Normal ranges for grip strength, pinch strength, and keypinch strength vary depending on age, sex, and hand dominance. However, a general reference for grip strength is 20 to 40 kg for men and 15 to 30 kg for women. For pinch strength, it is 6 to 12 kg for men and 5 to 10 kg for women. For keypinch strength, it is 4 to 8 kg for men and 3 to 7 kg for women.
These values may be lower in older adults or people with chronic conditions.
The client should expect some loss of strength in the affected hand after surgery, but it should gradually improve with rehabilitation.
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