A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?
Select a quiet location to talk to the client while remaining visible to staff members.
Give the client several clear options.
Observe the client and the situation.
Respect the client's personal space.
The Correct Answer is C
Rationale:
A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.
B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.
C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.
D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.
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Correct Answer is C
Explanation
Rationale:
A. Concerns about participation in team sports may indicate a desire for improved lung function but do not directly necessitate the use of a high-frequency chest compression vest.
B. Discomfort during nebulizer treatments may warrant alternative therapies, but it is not a direct indication for a high-frequency chest compression vest.
C. A small amount of mucus after percussion therapy suggests inadequate airway clearance, which may prompt the need for more effective techniques, such as the high-frequency chest compression vest, to facilitate mucus clearance and improve lung function.
D. A fever indicates a potential infection and requires further assessment but does not directly suggest the need for a high-frequency chest compression vest.
Correct Answer is C
Explanation
Rationale:
A. Applying a cold compress is not recommended for DVT; instead, heat may be more appropriate to alleviate discomfort and improve circulation.
B. Massaging the affected extremity is contraindicated as it can dislodge the clot and lead to complications such as pulmonary embolism.
C. Instructing the client to elevate the affected extremity helps reduce swelling and promote venous return, making it the best action.
D. Assessing pulses proximal to the affected area is important for monitoring circulation, but it is not the primary intervention for managing DVT.