The emergency department nurse is caring for a client who arrived after a motor vehicle accident. The client begins yelling, "No one is helping me!" and attempts to get out of bed, pulling at monitoring equipment. The client's heart rate is 128/min and respirations are rapid.
Which action should the nurse take first?
Leave the room to allow the client to calm down.
Ask the client about what they do at home when they feel anxious.
Stay with the client, position yourself near the door, and speak in a calm, reassuring manner.
Tell the client, "You need to calm down so we can help you.”.
The Correct Answer is C
Acute trauma causes physiological and psychological distress, often manifesting as agitation or panic. Resolving this requires applying crisis intervention principles, prioritizing safety, and using therapeutic communication to de-escalate the client while monitoring for signs of worsening physical or mental instability.
Choice A rationale
Leaving an agitated, tachycardic client alone is unsafe. The client may fall, pull out invasive lines, or suffer a physiological crisis. Constant observation is necessary to maintain physical safety and monitor a heart rate exceeding 100/min.
Choice B rationale
While understanding coping mechanisms is part of psychosocial assessment, it is not the priority during an acute, agitated crisis. The immediate need is to stabilize the client and ensure safety before exploring long-term behavioral patterns.
Choice C rationale
Staying with the client provides immediate support and safety. Positioning near the door ensures nurse safety, while calm communication reduces sympathetic nervous system overactivity, helping to lower a heart rate of 128/min and rapid respirations.
Choice D rationale
Commanding a distressed client to calm down is often counterproductive and non-therapeutic. It minimizes the client's feelings and can increase agitation. Therapeutic intervention requires a calm presence rather than authoritative demands during a traumatic event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Accurate estimation of burn size is critical for fluid resuscitation and metabolic support. This scenario requires applying the Rule of Nines, which assigns specific percentages to body regions to quantify the total body surface area affected by thermal injury.
Step 1 is 18 percent for the entire back area.
Step 2 is 18 percent for the anterior and posterior surfaces of the right leg.
Step 3 is 18 percent for the anterior and posterior surfaces of the left leg.
Step 4 is 9 percent for the left arm.
Step 5 is 18 + 18 + 18 + 9 = 63 percent total body surface area.
Correct Answer is A
Explanation
This scenario requires the application of electrocardiography interpretation skills to identify specific cardiac arrhythmias based on rhythm regularity, presence of P waves, and heart rate. Recognizing atrial fibrillation is essential for determining appropriate anticoagulation and rate control interventions for telemetry clients.
Choice A rationale
Atrial fibrillation is characterized by an irregularly irregular rhythm and a lack of discernible P waves. The rapid, disorganized electrical activity in the atria leads to ineffective pumping and increased risk for thromboembolic events or symptomatic palpitations.
Choice B rationale
Sinus tachycardia follows a regular rhythm with identifiable P waves preceding every QRS complex. The rate is typically between 101 and 150 beats per minute. This does not match the irregularly irregular rhythm or absent P waves described.
Choice C rationale
First degree heart block involves a delayed conduction through the atrioventricular node, resulting in a prolonged PR interval greater than 0.20 seconds. However, the rhythm remains regular with a 1 to 1 ratio of P waves to QRS.
Choice D rationale
Ventricular tachycardia presents as three or more consecutive premature ventricular contractions with a rate usually exceeding 100 per minute. It shows wide, bizarre QRS complexes and is typically a regular rhythm, which is inconsistent with this client strip.
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