The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?
Center attention on positive upbeat music.
Find outlets for more social interaction.
Practice using muscle relaxation techniques.
Think about reasons the episodes occur.
The Correct Answer is C
Choice A: Centering attention on positive upbeat music is not a specific instruction for the nurse to include, as this is a general coping strategy that may or may not be helpful for this client. This is a distractor choice.
Choice B: Finding outlets for more social interaction is not a relevant instruction for the nurse to include, as this may not address the underlying causes of anxiety or stress for this client. This is another distractor choice.
Choice C: Practicing using muscle relaxation techniques is an appropriate instruction for the nurse to include, as this can help reduce physical tension and promote calmness and relaxation for this client. Therefore, this is the correct choice.
Choice D: Thinking about reasons the episodes occur is not a helpful instruction for the nurse to include, as this can increase rumination and anxiety for this client. This is another distractor choice.
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Correct Answer is D
Explanation
Choice A: Administering a half dose now is not a safe instruction for the nurse to provide, as this can result in overdosing or underdosing the infant, depending on how much of the medicine was absorbed or expelled. This is a contraindicated choice.
Choice B: Giving another dose is not a prudent instruction for the nurse to provide, as this can cause digoxin toxicity, which can be life-threatening for the infant. This is another contraindicated choice.
Choice C: Mixing the next dose with food is not a relevant instruction for the nurse to provide, as this does not address the current situation and can affect the absorption and effectiveness of digoxin. This is a distractor choice.
Choice D: Withholding this dose is a sensible instruction for the nurse to provide, as this can prevent adverse effects and allow the infant's serum digoxin level to be checked before giving another dose. Therefore, this is the correct choice.
Correct Answer is D
Explanation
The correct answer is: D. Redress the abdominal incision
Choice A: Replace the IV catheter with a smaller gauge
Replacing the IV catheter with a smaller gauge is not directly addressing the issue of the client’s confusion and agitation. While a smaller gauge might be less irritating, it does not solve the problem of the client picking at the IV site. The pinkness at the IV site suggests mild irritation or early signs of phlebitis, which can be managed by monitoring and ensuring proper securement and care of the IV site.
Choice B: Apply soft bilateral wrist restraints
Applying wrist restraints should be a last resort due to the potential for causing distress, agitation, and physical harm to the patient. Restraints can lead to negative outcomes such as decreased circulation, pressure ulcers, and increased agitation, especially in patients with dementia. It is generally recommended to use less restrictive measures first.
Choice C: Leave the light on in the room at night
Leaving the light on in the room at night (C) can help reduce confusion and agitation in dementia patients, a phenomenon known as sundowning. However, it does not address the immediate issue of the non-occlusive dressing and the pink IV insertion site.
Choice D: Redress the abdominal incision
Given the situation, the most appropriate intervention would be to redress the abdominal incision (D). This is because the dressing is no longer occlusive, which can increase the risk of infection. Ensuring the dressing is secure and clean is crucial for the patient's safety.
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