A nurse in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect?

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically.
It also shows empathy and respect for the client’s perspective.
Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.
The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.
Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.
Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.
This is personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.
Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.
Choice D is wrong because initiating the seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.
Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.
It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.
Secluding an agitated client may escalate their behavior and violate their rights.
Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.
However, some tools that can be used to assess agitation include the Richmond Agitation- Sedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).

The correct answer is choice b. Remove the device from the room.

Choice A rationale:

Reporting the defect to the equipment maintenance staff is important, but the immediate priority is to ensure the client’s safety by removing the faulty device.

Choice B rationale:

Removing the device from the room is the first action to take to prevent any potential electrical hazards or injuries to the client.

Choice C rationale:

Initiating a requisition for a replacement CPM device is necessary but should be done after the faulty device has been removed to ensure safety.

Choice D rationale:

Ensuring the device inspection sticker is current is part of routine checks, but it does not address the immediate safety concern posed by the frayed cord.