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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: While evacuation is typically the first course of action during an active shooter situation, it is not feasible if the shooter is rapidly approaching and exits are not accessible. In such scenarios, finding a safe place to hide is a better immediate response.

Choice B reason: Hiding in a room with no windows is an appropriate action when the shooter is nearby, and evacuation is not possible. Locking the door, turning off lights, and remaining silent can increase the chances of avoiding detection by the shooter. This response prioritizes immediate safety.

Choice C reason: Attacking the shooter should only be considered as a last resort when there are no other options for escape or hiding, and one's life is in imminent danger. It is not the next best action in this scenario when hiding is a viable option.

Choice D reason: Calling emergency services is crucial, but if the shooter is rapidly approaching, immediate action to protect oneself by hiding takes precedence. Once in a secure location, contacting emergency services should follow.

A. Red B. Yellow C. Black D. Green

Correct Answer is B

Explanation

Choice A reason: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention.

Choice B reason: The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level.

Choice C reason: The black category is used for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is stable and responsive, so they do not fall into this category.

Choice D reason: The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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