A client with bleeding esophageal varices receives vasopressin intravenously (IV). Which adverse effect should the nurse monitor for during the IV infusion of this medication?

The correct answer is choice B. “You seem quite frightened right now.”.

Choice A rationale:

While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.

Choice B rationale:

Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.

Choice C rationale:

Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.

Choice D rationale:

Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.

The correct answer and explanation are:

A - Ask the client to describe what happened. Correct

This is the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Asking the client to describe what happened shows empathy, respect, and active listening, and allows the PN to gather more information and validate the client's feelings and concerns. The PN should also apologize for the delay, assess the client's pain level and needs, and provide appropriate interventions and support.

B - Inform the charge nurse of the situation.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Informing the charge nurse of the situation may be necessary, but it should be done after addressing the client's immediate needs and concerns. The PN should not ignore or avoid the client, but should communicate with him and try to resolve the issue.

C - Complete a client adverse incident report.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times.

Completing a client adverse incident report may be required, but it should be done after addressing the client's immediate needs and concerns. The PN should not prioritize documentation over care, but should provide timely and effective pain management and support to the client.

D - Call the agency-based client advocate.

This is not the first action that the PN should implement when the UAP tells them that a male client is angry because the night shift took over 2 hours to bring him the pain medication, he had to request three times. Calling the agency-based client advocate may be helpful, but it should be done after addressing the client's immediate needs and concerns.

The PN should not delegate or defer responsibility for care, but should communicate with the client and try to resolve the issue. The PN should also respect the client's right to choose whether or not to involve an advocate in his care.