A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.

Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Engage the panic alarm

Use a face shield with a mask when providing care to the client.

Tell the client, “You seem to be very upset.”

Initiate seclusion protocol.

Answer and Explanation

The Correct Answer is C

Tell the client, “You seem to be very upset.”.

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 a 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 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 AgitationSedation 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).

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Correct Answer is A

Explanation

The correct answer is choice A. INR.

Warfarin is a vitamin K antagonist that inhibits the synthesis of factors II, VII, IX, and X in the liver.

These factors are part of the extrinsic and common pathways of coagulation, which are measured by the prothrombin time (PT) and the international normalized ratio (INR).

The INR is a standardized way of reporting the PT that accounts for the variability of different reagents and instruments.

The INR is used to monitor the therapeutic effect of warfarin and to adjust the dose accordingly.

The target INR range depends on the indication for warfarin, but it is usually between 2 and 3 for most conditions.

Choice B is wrong because fibrinogen level is not affected by warfarin.

Fibrinogen is a precursor of fibrin, which forms the final step of the coagulation cascade.

Fibrinogen level can be decreased in conditions such as disseminated intravascular coagulation (DIC), liver disease, or severe bleeding. Choice C is wrong because aPTT is not affected by warfarin.

aPTT measures the intrinsic and common pathways of coagulation, which are mainly dependent on factors VIII, IX, XI, and XII.

These factors are not inhibited by warfarin.

aPTT is used to monitor the effect of heparin, a direct antithrombin agent that inhibits thrombin and factor Xa.

Choice D is wrong because platelet count is not affected by warfarin.

Platelets are cell fragments that adhere to damaged blood vessels and form aggregates to initiate hemostasis.

Platelet count can be decreased in conditions such as immune thrombocytopenia (ITP), heparin-induced thrombocytopenia (HIT), or bone marrow suppression.

Normal ranges:

INR: 0.8-1.2
Fibrinogen: 200-400 mg/dL
aPTT: 25-35 seconds
Platelet count: 150-450 x 10^9/L References:

A. Ketorolac B. Acetaminophen C. Aspirin D. Ibuprofen

Correct Answer is B

Explanation

Choice A reason:

Ketorolac is incorrect because it is an NSAID that is used for short-term pain relief. It has a higher risk of causing irritation to the stomach lining and is not recommended for clients with a history of peptic ulcers.

Choice B reason:

Acetaminophen is the correct answer. When caring for a client who reports a headache and has a history of a peptic ulcer, the nurse should administer Acetaminophen. Acetaminophen is an analgesic (pain reliever) and antipyretic (fever reducer) that does not have anti-inflammatory properties. It is a suitable option for pain relief in clients with a history of peptic ulcers because it is less likely to cause irritation to the stomach lining compared to nonsteroidal anti-inflammatory drugs (NSAIDs).

Choice C reason

Aspirin is not appropriate: Aspirin is an NSAID with anti-inflammatory, analgesic, and antipyretic properties. Like other NSAIDs, it can increase the risk of stomach irritation and should be avoided in clients with a history of peptic ulcers.

Choice D reason:

Ibuprofen is not the right option: Ibuprofen is another NSAID commonly used for pain relief and reducing inflammation and fever. Like other NSAIDs, it can irritate the stomach lining and is not recommended for clients with a history of peptic ulcers.

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A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

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Correct Answer is B

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A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.

Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?