A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
Call a chaplain
Maintain the client’s blood pressure
Provide the spouse a chair
Ask the client’s spouse to explain what happened
The Correct Answer is B
Choice A reason: Calling a chaplain is not the priority nursing action for a client who is in critical condition and hypotensive. The chaplain may not be available or may not be able to provide adequate support to the spouse. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Choice B reason: Maintaining the client’s blood pressure is the priority nursing action for a client who is in critical condition and hypotensive. The nurse should monitor the client’s vital signs, administer fluids and medications, and provide oxygen as ordered. This choice addresses the client’s urgent medical needs and may prevent further complications.
Choice C reason: Providing the spouse a chair is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not want to sit down or may not be able to stay calm. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Choice D reason: Asking the client’s spouse to explain what happened is not the priority nursing action for a client who is in critical condition and hypotensive. The spouse may not be able to recall or communicate the details of the event. This choice does not address the client’s urgent medical needs or the spouse’s emotional needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A decreased level of rheumatoid factor is not seen in clients with rheumatoid arthritis. Rheumatoid factor is an antibody that is produced by the immune system and can bind to other antibodies. A high level of rheumatoid factor indicates an autoimmune disorder, such as rheumatoid arthritis.
Choice B reason: A negative rheumatoid factor is not seen in clients with rheumatoid arthritis. A negative rheumatoid factor means that the antibody is not detected in the blood. A negative rheumatoid factor does not rule out rheumatoid arthritis, but it may suggest a different type of arthritis or another condition.
Choice C reason: A positive rheumatoid factor is seen in clients with rheumatoid arthritis. A positive rheumatoid factor means that the antibody is detected in the blood. A positive rheumatoid factor is more likely to occur in clients with rheumatoid arthritis, especially during a flareup of the disease.
Choice D reason: Factor does not change is not seen in clients with rheumatoid arthritis. Rheumatoid factor can vary over time and may change depending on the activity of the disease. Rheumatoid factor may increase during a flareup and decrease during remission.
Correct Answer is B
Explanation
Choice A reason: "Tomorrow will be better." is not a statement that demonstrates empathy, but rather one that demonstrates false reassurance or denial. False reassurance or denial is a communication barrier that dismisses or minimizes the client's feelings or concerns, and offers unrealistic or vague promises that may not be fulfilled. False reassurance or denial can make the client feel invalidated, misunderstood, or hopeless.
Choice B reason: "This must be hard news to hear. Tell me more about it." is a statement that demonstrates empathy, which is the ability to understand and share the feelings of another person. Empathy is a communication skill that acknowledges and validates the client's feelings or concerns, and invites the client to express and explore them further. Empathy can make the client feel supported, respected, and empowered.
Choice C reason: "What is your biggest fear about this diagnosis?" is not a statement that demonstrates empathy, but rather one that demonstrates probing or prying. Probing or prying is a communication barrier that asks intrusive or inappropriate questions that may make the client feel uncomfortable, defensive, or threatened. Probing or prying can make the client feel violated, judged, or pressured.
Choice D reason: "I believe you can overcome this because I've seen how strong you are." is not a statement that demonstrates empathy, but rather one that demonstrates stereotyping or labeling. Stereotyping or labeling is a communication barrier that assigns a fixed or generalized characteristic to a person or a situation, without considering the individuality or uniqueness of the person or the situation. Stereotyping or labeling can make the client feel objectified, devalued, or misunderstood.
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