The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
Ask the client to describe the history of the injuries.
Invite a colleague to document during the interview.
Close the examination room door for privacy.
Request hospital security to come to the department.
The Correct Answer is C
A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.
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Related Questions
Correct Answer is D
Explanation
A. Using relaxation techniques is a positive and appropriate strategy for managing anxiety.
B. Avoiding alcohol and other sedatives is essential as they can potentiate the sedative effects of lorazepam.
C. Moving slowly from a sitting to a standing position is important to minimize orthostatic hypotension, a potential side effect of lorazepam.
D. Stopping the medication if the intended effect is not immediate is not appropriate guidance.
Lorazepam, like many benzodiazepines, may take some time to achieve its full therapeutic effect. Abrupt discontinuation can lead to withdrawal symptoms and should be done under the guidance of a healthcare provider.
Correct Answer is C
Explanation
A. Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B. Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D. Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.
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