The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?
Arrange for the client to remain on bedrest.
Tell the client to remain calm.
Encourage the client to share their feelings.
Give the client time to rest and return later for your assessment.
The Correct Answer is C
Choice A reason: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support.
Choice B reason: Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves.
Choice C reason: Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan.
Choice D reason: Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While evaluating what went wrong and developing policies for future incidents is important, this statement is more suited for an after-action review or a quality improvement session. A critical incident stress debriefing focuses on the emotional and psychological support for staff rather than policy evaluation.
Choice B reason: Excluding ancillary personnel from the debriefing session is inappropriate. All staff involved in the incident, including ancillary personnel, should be included in the debriefing to address their emotional and psychological needs. This statement does not support the inclusive nature of debriefing sessions.
Choice C reason: Passing around the disaster written policy for review is not appropriate for a stress debriefing session. The purpose of a debriefing is to provide a safe space for staff to express their emotions and experiences rather than reviewing policies.
Choice D reason: This statement is appropriate for a critical incident stress debriefing as it encourages staff to express their feelings openly and assures them of confidentiality. Creating a safe and supportive environment is essential for addressing the emotional and psychological impact of the incident on staff.
Correct Answer is B
Explanation
Choice A reason: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements.
Choice B reason: This client received tissue plasminogen activator (tPA) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority.
Choice C reason: The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care.
Choice D reason: The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tPA. While aspirin is important for preventing further strokes, it does not require the same level of immediate monitoring as the post-tPA client.
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