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 D
Explanation
Rationale:
A. Decreased cholesterol is not a primary effect of chlorpromazine; the medication is primarily used for psychiatric conditions, not lipid management.
B. While chlorpromazine may have sedative effects that could impact blood pressure, decreased blood pressure is not a direct indicator of its effectiveness in treating psychiatric symptoms.
C. Decreased esophageal reflux is not a relevant effect of chlorpromazine, as it is primarily used for managing psychotic symptoms.
D. Decreased hallucinations is a direct indication of the medication's effectiveness in treating conditions such as schizophrenia or other psychotic disorders, as chlorpromazine is an antipsychotic medication.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.
B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.
C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.
E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.