A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Let each family member ask a question one at a time.

Request the healthcare provider to speak with the family.

Ask the family to identify a specific spokesperson.

Page a chaplain on call to be present for questions.

Answer and Explanation

The Correct Answer is C

A) This intervention is not the best because it may take too much time and energy from the nurse, who needs to focus on the client's critical condition. The nurse may also have to repeat the same information multiple times, which can be frustrating and confusing for both the nurse and the family.

B) This intervention is not the best because it may not be feasible or appropriate at this time. The healthcare provider may be busy with other clients or procedures, and may not be able to speak with the family right away. The healthcare provider may also need to obtain the client's consent or permission before disclosing any information to the family, which may not be possible if the client is sedated.

C) This intervention is the best because it can help reduce the number and frequency of questions, and facilitate clear and consistent communication between the nurse and the family. The nurse can ask the family to choose one person who will act as their representative and spokesperson, and who will relay any information or updates to the rest of the family. This can also help respect the client's privacy and confidentiality, and prevent any conflicting or contradictory messages.

D) This intervention is not the best because it may not address the family's informational needs or preferences. The chaplain on call may provide spiritual or emotional support to the family, but may not be able to answer any medical or technical questions. The family may also have different religious or cultural beliefs that may not align with the chaplain's role or perspective.

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Correct Answer is A

Explanation

Choice A Reason: This role is responsible for coordinating the continuum of care for clients with complex health needs, such as head injury. The nurse case manager collaborates with the interdisciplinary team, the client, and the family to plan, implement, and evaluate the client's care from admission to discharge.

Choice B Reason: This role is responsible for providing primary and specialty care to adults, such as diagnosing and treating acute and chronic conditions, prescribing medications, and ordering tests. The adult nurse practitioner may be involved in the client's care, but not in coordinating it.

Choice C Reason: This role is responsible for managing the daily operations of the neurology unit, such as staffing, budgeting, quality improvement, and staff development. The neurology unit supervisor may oversee the client's care while on the unit, but not throughout the continuum of care.

Choice D Reason: This role is responsible for identifying and preventing potential risks and liabilities in the healthcare setting, such as errors, injuries, infections, or lawsuits. The risk management nurse may monitor the client's care for quality and safety issues, but not for coordination.

A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill. B. Instruct the clients' family members to stay in the visitor waiting area until further notice. C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Correct Answer is D

Explanation

Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.

Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.

Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.

Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.

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A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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