While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.
What is the most appropriate action for the nurse to take?
Reassure the client that the nurse will return after all vital signs are taken.
Pull up a chair and sit beside the client’s bed.
Allow the client to hold the nurse’s hand until the vital signs can be completed.
Tell the client that he must release the nurse’s hand.
The Correct Answer is B
Choice A rationale
Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.
Choice B rationale
Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.
Choice C rationale
Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.
Choice D rationale
Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.
Choice B rationale
Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.
Choice C rationale
Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.
Choice D rationale
Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.
Correct Answer is B
Explanation
Choice A rationale
A blood pressure of 100/60 mm Hg is not typically considered a risk for patients receiving eptifibatide. While eptifibatide can cause hypotension, a blood pressure of 100/60 mm Hg is within normal limits.
Choice B rationale
The presence of hematemesis, or vomiting blood, poses the greatest risk to the patient. Eptifibatide is a glycoprotein IIb/IIIa inhibitor that prevents platelets from clumping together by blocking the action of certain proteins. This can increase the risk of bleeding, including gastrointestinal bleeding, which could manifest as hematemesis.
Choice C rationale
Incontinence with blood in the urine could indicate a urinary tract infection or other urinary system issue, but it is not typically associated with the use of eptifibatide.
Choice D rationale
Unresponsiveness to painful stimuli is a serious symptom that could indicate a number of issues, including neurological damage or severe illness. However, it is not typically associated with the use of eptifibatide.
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