While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.
What is the most appropriate action for the nurse to take?

Reassure the client that the nurse will return after all vital signs are taken.

Pull up a chair and sit beside the client’s bed.

Allow the client to hold the nurse’s hand until the vital signs can be completed.

Tell the client that he must release the nurse’s hand.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

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Free Nursing Study Resources

Correct Answer is C,A,D,B

Explanation

Step 1: Observe breathing patterns. Respiratory depression is a critical symptom of myxedema coma that requires immediate attention.

Step 2: Measure body temperature. Hypothermia is a common symptom of myxedema coma and can provide important information about the severity of the patient’s condition.

Step 3: Assess blood pressure. Hypotension can occur in myxedema coma and can indicate the severity of the patient’s condition.

Step 4: Palpate for pedal edema. While this can be a symptom of hypothyroidism, it is not typically a primary concern in a patient showing signs of myxedema coma.

A. Auscultate an area six inches below the umbilicus. B. Observe the appearance of the patient’s urine. C. Palpate the area above the pubic symphysis. D. Measure the girth of the patient’s lower abdomen.

Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with primary hypothyroidism is showing early signs of myxedema coma. In what order should the nurse perform the following assessments? (Rank the first action at the top with the remainder in descending order.)

Correct Answer is C,A,D,B

Explanation

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

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Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.
What is the most appropriate action for the nurse to take?