A nurse is caring for a client who is scheduled for a procedure, but the client states that they no longer want to undergo the procedure. Which of the following actions should the nurse take?

A. "We can discuss this after completing the admission process." Delaying discussion about the client’s aggression may leave the partner feeling unheard and unsupported during an emotionally charged moment. Immediate acknowledgement is important to build trust and provide reassurance.

B. "Your partner is in the denial stage of grief." Verbal aggression is not typically linked to the denial stage of grief, which is more about avoidance or disbelief. Aggression is more often related to frustration, fear, or physiological changes at end of life.

C. "You should discuss this problem with your family members." Redirecting the partner to family members does not address their concerns directly and can seem dismissive. The nurse should provide direct support and clear information to help the partner understand the client’s behavior.

D. "Your partner is experiencing an expected response to the dying process." Verbal aggression can be a normal reaction to the stress, pain, or neurological changes associated with the dying process. Providing this explanation helps normalize the behavior, reducing anxiety for the partner and promoting understanding.

Rationale for Correct Answers:

• Turn the client to their side: This is a crucial first action. During a seizure, turning the client to their side (recovery position) helps to maintain an open airway, prevent aspiration of saliva or vomitus, and allow secretions to drain from the mouth.
• Call for assistance: After ensuring the client's safety and positioning, the nurse should call for help to ensure appropriate and prompt support from the healthcare team.

Rationale for Incorrect Answers:

• Restrain the client: Restraining a client during a seizure can cause injury. Instead, ensure the area is safe and the client is protected from harm without restricting movement.
• Place a tongue blade in the client’s mouth: This is unsafe and outdated. Inserting anything in the mouth during a seizure can break teeth or obstruct the airway.
• Administer lorazepam: Although lorazepam is used to treat ongoing prolonged seizures, it is not the first action in this scenario. Medication administration follows basic safety measures and calling for support.