A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients.

Which action should the practical nurse (PN) implement first?

The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.

Choice A rationale:

This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.

Choice B rationale:

Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.

Choice C rationale:

Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.

Choice D rationale:

Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.

The correct answer is choice A: Have the client sit down in the hall.

Choice A rationale: The PN should first have the client sit down to help alleviate the client's chest tightness and shortness of breath. Sitting down allows for better lung expansion and reduces the risk of falling due to dizziness or lightheadedness. This is the most appropriate initial action in response to the client's complaint.

Choice B rationale: While assisting the client back to their room is important, the PN should first ensure that the client is sitting down to help manage their symptoms. After the client is seated and more stable, the PN can then assist them back to their room for further assessment and intervention.

Choice C rationale: Administering sublingual nitroglycerin may be appropriate if the client is experiencing cardiac-related chest pain. However, the PN should first have the client sit down and gather more information about their symptoms before administering any medications.

Choice D rationale: Obtaining a 12-lead electrocardiogram can help assess the client's cardiac status, but it is not the first action that the PN should take in this situation. Ensuring the client's safety and managing their symptoms are immediate priorities. The PN can consider obtaining an electrocardiogram after addressing the client's immediate needs and assessing their condition further.