A nurse is assessing a client admitted to the ambulatory surgery unit. The client has diaphoresis with rapid pulse and respirations, elevated blood pressure, and dilated pupils
When the nurse attempts to reinforce preoperative teaching, the client cannot remember anything about previous instructions. Which of these nursing actions is MOST appropriate? a. Administer the prescribed preoperative medication now.
b. Ask the client to describe what is wrong.
c. Slowly repeat all preoperative instructions.
d. Notify the surgeon of the client's emotional status.
D
Mildly anxious clients should receive the most complete instructions. Moderately anxious clients receive less information but more attention to specific areas of concern. Severely anxious clients receive only basic information but are encouraged to verbalize their concerns. Clients in a state of panic are unable to learn; in such cases, no instructions are given and the surgeon is notified.
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