A young adult is brought to the emergency department after taking a handful of drugs.

The client is unresponsive, so an endotracheal tube (ETT) is inserted.

How should the nurse determine if the ETT is correctly placed? (Select all that apply.).

Choice A rationale: Orange juice contains pulp and is not considered a clear liquid. A clear liquid diet is restricted to fat-free liquids and those that are transparent at room temperature.

Choice B rationale: Apple juice is a transparent liquid that remains liquid at room temperature. It provides carbohydrates and fluid without leaving residue in the gastrointestinal tract, fitting the clear liquid requirement.

Choice C rationale: Hot chocolate contains dairy or cocoa solids, making it an opaque liquid. It is excluded from a clear liquid diet and also contains caffeine, which Mormons typically avoid.

Choice D rationale: Chicken broth is a clear, fat-free liquid that provides electrolytes and hydration. It is an essential component of a clear liquid diet and does not violate any Mormon dietary restrictions.

Choice E rationale: Black coffee is a caffeinated beverage. The Word of Wisdom in Mormon belief prohibits the consumption of "hot drinks," specifically interpreted as coffee and tea, regardless of the diet type.

Choice A rationale:

Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.

Choice B rationale:

Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.

Choice C rationale:

Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.

Choice D rationale:

Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.