A patient with a new pulmonary embolism (PE) is anxious.
What nursing actions are most appropriate? Select all that apply.
Acknowledge the frightening nature of the illness.
Give simple explanations of what is happening.
Request a prescription for antianxiety medications.
Stay with the patient and speak in a quiet, calm voice.
Correct Answer : A,B,D
Choice A rationale
Acknowledging the frightening nature of the illness is a crucial therapeutic communication technique. By validating the patient's feelings of fear and anxiety, the nurse establishes trust and rapport. This approach shows empathy and helps the patient feel understood, which can reduce psychological distress. It also provides a foundation for the patient to be more receptive to subsequent nursing interventions and education.
Choice B rationale
Providing simple, clear explanations of what is happening helps to demystify the situation and reduce the patient's anxiety. When a person is anxious, their cognitive processing can be impaired, making it difficult to comprehend complex information. Short, concise explanations about the cause of their symptoms and the purpose of interventions can help the patient feel more in control and less overwhelmed, thereby alleviating some of their fear.
Choice C rationale
Requesting a prescription for antianxiety medications is not the most appropriate immediate action. While medications may eventually be necessary, the initial nursing actions should focus on non-pharmacological interventions. These include therapeutic communication and supportive presence. Pharmacological interventions are typically reserved for situations where non-pharmacological methods are insufficient or the anxiety is severe enough to cause physiological instability.
Choice D rationale
Staying with the patient and speaking in a quiet, calm voice is a primary nursing action for an anxious patient. A calm, reassuring presence can help to de-escalate the patient's anxiety by providing a sense of security and support. The nurse's calm demeanor can also model appropriate emotional regulation for the patient, which can help to reduce their physiological and psychological distress. This action is simple, immediate, and highly effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Pursed-lip breathing is a technique used to slow down the breathing rate and facilitate a more complete exhalation, primarily beneficial for patients with obstructive lung diseases like COPD. It does not provide the positive intrathoracic pressure necessary to prevent air from entering the pleural space during a chest tube removal.
Choice B rationale
Lying flat and breathing deeply does not create the necessary positive pressure within the pleural cavity. This action would not prevent air from being sucked into the chest cavity, leading to a potential pneumothorax. The patient needs to increase intrathoracic pressure to seal the site.
Choice C rationale
The Valsalva maneuver, which involves taking a deep breath, holding it, and bearing down, increases intrathoracic pressure. This positive pressure helps to prevent air from rushing back into the pleural space when the chest tube is removed, thus minimizing the risk of a tension pneumothorax.
Choice D rationale
Rapid breathing, or hyperventilation, would decrease intrathoracic pressure and could potentially cause more air to be drawn into the pleural space upon removal of the chest tube. This action could lead to a tension pneumothorax. *.
Correct Answer is B
Explanation
Choice A rationale
Contact dermatitis is an inflammatory reaction of the skin caused by contact with an irritant or allergen. Avoiding hot showers and baths is a correct teaching point, as heat can exacerbate itching and further irritate the skin barrier, leading to increased inflammation and discomfort. This statement shows correct understanding.
Choice B rationale
Contact dermatitis is not contagious. The rash is a localized inflammatory response and cannot be spread from person to person. A statement about isolating oneself indicates a significant misunderstanding of the condition's etiology and transmission. This is the statement that requires further education from the nurse.
Choice C rationale
Applying unscented moisturizer is a correct and helpful intervention for contact dermatitis. Moisturizers help to restore the skin's barrier function, reduce dryness and scaling, and can soothe the irritated area. Using an unscented product is important to avoid further irritation from potential allergens in fragrances.
Choice D rationale
Maintaining adequate hydration is beneficial for overall skin health and can support the skin's healing process. While 100 oz may be a large amount for some, drinking adequate fluids is generally a sound recommendation for promoting skin barrier function and systemic health during an inflammatory process. .
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