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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A.
Weight loss.
Furosemide is a loop diuretic that is used to treat fluid volume excess by increasing the excretion of water and electrolytes through the kidneys. Weight loss is an indication that the medication has been effective in reducing the excess fluid in the body.
Choice B is wrong because decreased inflammation is not a direct effect of furosemide.
Inflammation is a response to tissue injury or infection, and furosemide does not have any anti-inflammatory properties.
Choice C is wrong because increased blood pressure is not an indication of furosemide effectiveness.
Furosemide lowers blood pressure by reducing the preload and afterload on the heart.
Increased blood pressure may indicate that the dose of furosemide is insufficient or that there are other factors contributing to hypertension.
Choice D is wrong because decreased pain is not an expected outcome of furosemide therapy.
Furosemide does not have any analgesic effects, and pain may be caused by various conditions that are not related to fluid volume excess.
Normal ranges for weight, blood pressure and pain vary depending on the individual patient’s baseline and goals.
However, some general guidelines are:
- Weight: A weight loss of 0.5 to 1 kg per day is considered safe and effective for patients with fluid volume excess.
- Blood pressure: The target blood pressure for most patients with heart failure is less than 130/80 mmHg.
- Pain: The pain level should be assessed using a valid and reliable scale, such as the numeric rating scale or the visual analogue scale, and treated according to the patient’s preference and tolerance.
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should include that information technology will install a firewall to secure client information.
A firewall is a system that protects the network from unauthorized access and prevents data breaches. A firewall is essential for ensuring the confidentiality, integrity, and availability of electronic health records .
Choice A is wrong because the nurse should change their password more frequently than once per year. Changing passwords regularly reduces the risk of unauthorized access and enhances security .
Choice B is wrong because the documentation of sensitive material is not performed by the charge nurse. The nurse who provides the care should document it accurately and promptly in the computerized system .
Choice C is wrong because the nurse will not be given access to the medical records of every client in the facility. The nurse should only access the records of the clients they are assigned to care for, following the principle of need-to-know .
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