The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Ask the client to describe the history of the injuries.

Invite a colleague to document during the interview.

Close the examination room door for privacy.

Request hospital security to come to the department.

Answer and Explanation

The Correct Answer is C

A.   While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B.   Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D.   Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.

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Correct Answer is B

Explanation

A. Providing the client with written information about privacy laws is a good practice, but a verbal explanation is also necessary to address the immediate concern.
B. This response provides accurate information about confidentiality while acknowledging exceptions when safety is at risk.
C. Non-verbal gestures may be ambiguous and could lead to misunderstandings. It's important to communicate clearly with the client.
D. Assuring the client that information will be shared only with the staff may not be entirely accurate, as there are situations where confidentiality must be breached, such as when safety is a concern.

A. Sit in the chair next to the client. B. Listen to what the client is saying. C. Escort the client to his room. D. Administer a PRN sedative.

Correct Answer is B

Explanation

A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

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The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Nursing Test Bank

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