What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Reduce environmental stimuli

Suction the oropharynx

Assess pulse oximetry

Administer oxygen

Answer and Explanation

The Correct Answer is A

A. Restlessness and agitation in nonverbal clients can often be exacerbated by environmental factors such as noise, bright lights, or unfamiliar surroundings. By reducing environmental stimuli, such as dimming lights, minimizing noise, and providing a calm atmosphere, the nurse can help alleviate agitation and promote a more comfortable environment for the client.

B. Suctioning the oropharynx is not typically the first action unless there is a clear indication that airway obstruction or secretion management is contributing to the client's agitation. It is important to first assess whether there are signs of respiratory distress or airway compromise before performing suctioning.

C. Assessing pulse oximetry is important for monitoring oxygen saturation levels, especially if there are concerns about respiratory distress or inadequate oxygenation. However, it is not typically the first action when a client is restless and agitated unless there are specific indications or signs suggesting respiratory compromise.

D. Administering oxygen may be necessary if there are signs of hypoxia or respiratory distress contributing to the client's agitation. However, without assessing the client's oxygenation status first, administering oxygen as the initial action may not address the underlying cause of agitation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Previous experiences with pain can significantly influence how individuals perceive and respond to pain in the future. Positive experiences may lead to better coping strategies, while negative experiences could increase fear and anxiety associated with pain.

B. Cultural beliefs, norms, and practices surrounding pain vary widely across different societies. Culture shapes how individuals express pain, interpret pain severity, and seek treatment. For instance, some cultures may encourage stoicism in the face of pain, while others may emphasize the importance of verbalizing discomfort.

C. Socioeconomic status can impact access to healthcare resources, including pain management options. Higher SES individuals may have better access to healthcare facilities, medications, and therapies, whereas lower SES individuals may face barriers to adequate pain relief due to financial constraints or limited healthcare services.

D. Emotional states such as anxiety, depression, stress, and fear can significantly influence the perception and experience of pain. These emotions can amplify pain perception and interfere with pain management strategies. Conversely, positive emotions and a sense of well-being may help reduce the intensity of pain.

E. Age-related factors can affect how pain is perceived and managed. Children and older adults, for example, may experience pain differently due to developmental stages, cognitive abilities, and physiological changes. Pain assessment and management approaches need to be tailored accordingly to address age-specific considerations.

A. Introductory B. Noncongruent C. Nonverbal D. Congruent

Correct Answer is D

Explanation

D. Congruent communication occurs when verbal and nonverbal messages are consistent with each other. In the scenario, the nurse's direct eye contact, pleasant expression, and verbal statement ("The colostomy looks good") appear to be aligned and supportive of each other. This demonstrates congruence in communication, where both verbal and nonverbal cues are reinforcing a positive message to the client.

A. Introductory communication typically refers to the initial phase of interaction where the nurse establishes rapport, introduces themselves, and sets the tone for the interaction. This does not directly apply to the nurse's actions described in the scenario of changing a client's colostomy bag.

B. Noncongruent communication occurs when there is a mismatch between verbal and nonverbal messages. In this scenario, the nurse makes direct eye contact, has a pleasant expression, and verbally reassures the client that "the colostomy looks good." If these nonverbal cues (eye contact, pleasant expression) are not aligned with the verbal message (reassuring statement), it would be noncongruent communication. However, based on the scenario, it seems the nurse's nonverbal cues (eye contact, pleasant expression) support the verbal message, so this option is less likely.

C. Nonverbal communication includes gestures, facial expressions, eye contact, body language, and tone of voice. In the scenario described, the nurse demonstrates nonverbal communication by making direct eye contact and having a pleasant expression while interacting with the client. Nonverbal communication is an important aspect of nursing care as it conveys empathy, reassurance, and attentiveness to the client's needs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What should the nurse do first when caring for a nonverbal adult client who is restless & agitated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that various factors influence a client's pain. Which of the following factors could be influencers of pain? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse makes direct eye contact and has a pleasant expression on her face when changing a client's colostomy bag. The nurse tells the client, "The colostomy looks good." What type of communication is the nurse demonstrating?

Correct Answer is D

Explanation

Which example best illustrates the principle of the nurse "knowing" the client? The nurse:

When auscultating over the apex of the client's lung field, what breath sound should the nurse expect to hear?

Which response by the nurse best conveys empathy to the client?

what is the primary reason for a nurse to critically think about client care?

A nurse is caring for a client receiving 0.9% NSS infusing at 150 mL/hr. Which statement(s) made by the client should alert the nurse to suspect fluid overload? (SELECT ALL THAT APPLY)

The nurse finds a client's pulse to be very weak, but palpable. Documentation should note that this pulse is:

A client's father has recently died. Which response from the nurse would be most therapeutic?

The nurse assesses an open wound that is over the area of the client's greater trochanter. What finding would indicate to the nurse that this is a Stage IV pressure injury?