A female client receives CPR for 20 minutes when a teenager identifies herself as the client's daughter. The girl is very upset and thinks her mother is dead. Which response should the nurse implement first?
1. Instruct her to notify other family members.
2. Request the girl prove that she is the daughter.
3. Ask if her mother wanted to donate any organs.
4. Invite her to discuss the situation in another room.
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4. The best intervention for the nurse to implement is to invite the girl into another area, preferably with a door, and provide information about her mother, offer to call other family members, and answer her questions ensuring privacy and confidentiality. A visitor who is visibly upset is another disruption on a unit already managing a code; in addition, the visible distress is very distressing to clients and other visitors.
1. Instructing the girl to notify other family members at the onset implies the client has no hope of recovery; however, later in the discussion, the nurse offers to call other people for the girl, especially if she is alone.
2. Requesting the girl prove her identify is a reasonable request if the nurse and staff has never seen the person before this. Without asking the girl to identify herself di-rectly, the nurse can pose a few questions to verify the girl's identify because the nurse does not want to provide information to an unrelated party. Even if the girl is the daughter of the client, the nurse follows agency policy about disclosing confiden-tial information.
3. Asking about potential organ donation is premature and potentially cruel because the outcome of the code is undetermined. It is improper to discuss organ donation at this point because it implies the client has no hope of recovery; however, the nurse should become comfortable discussing organ donation with families near the end or at the conclusion of a code.
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