While preparing to administer a scheduled IV medication, the client tells the nurse that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

Rationale

A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.

B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority

should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

B. This statement suggests a misunderstanding or stigma associated with mental health diagnoses. It's important for the nurse to clarify that experiencing acute stress disorder or any other psychological response to trauma does not equate to being "crazy." This can help reduce stigma and promote understanding that such responses are normal reactions to abnormal situations.
E. This statement indicates a potential misunderstanding about the duration of medication use. Clonazepam, in this case, is prescribed to manage acute symptoms related to anxiety and sleep disturbance. The nurse should explain that medication use for psychological symptoms is typically temporary and part of a broader treatment plan that may include therapy and other interventions aimed at recovery and long-term well-being.
F. While acute stress disorder is a risk factor for developing post-traumatic stress disorder (PTSD), not everyone who experiences acute stress disorder will develop PTSD. It's important for the nurse to provide education about the differences between acute stress disorder and PTSD, their symptoms, and the importance of ongoing monitoring and support to prevent long-term psychological difficulties.