A patient tells the nurse, "I have been waiting two hours to be discharged. What is the problem?" The patient is pacing the room and glaring at staff members. What is the nurse's best action to prevent patient aggression?
1. Call hospital security to be prepared if the patient becomes aggressive.
2. Ask the patient to remain seated and retrieve the patient's discharge paperwork.
3. Acknowledge the patient's feelings and leave the room in order to avoid confrontation.
4. Acknowledge the patient's feelings and determine the status of the patient's discharge paperwork.
Answer: 4
Explanation: In most cases, aggressive behavior is a response to an unmet need, often combined with underlying anxiety and poor coping mechanisms. The patient is displaying cues to aggressive behavior by pacing the room and glaring at staff members. The nurse's best action is to acknowledge the patient's feelings and determine the status of the patient's discharge paperwork. This action will validate the patient's feelings and attempt to address the patient's unmet needs. Calling hospital security does not address the patient's needs, nor does asking the patient to remain seated without validating the patient's concerns. Acknowledging the patient's feelings is the correct intervention; however, the nurse should intervene early, not leave the patient alone in the room.
You might also like to view...
The 75-year-old client tells his nurse that this is the first time he will have had his intraocular pressure measured and that he only came because his daughter insisted
He also says that he is afraid the test will hurt and that he might find out he has glaucoma and will go blind. What is the nurse's best response? A. "The test is painless because you will receive a sedative. If you have glaucoma, the correct glasses or contact lenses can prevent blindness." B. "The test is quick and painless because a local anesthetic is used. Early detection of glaucoma allows medications and other procedures to prevent blindness." C. "The test does cause a little pain, but it is over very quickly. This test, however, does not determine whether or not you have glaucoma or are at risk for glauco-ma." D. "The test causes some pain and tearing, but you can have your daughter present to hold your hand. It is unlikely that you have glaucoma because no one in your family has it."
A client is experiencing brash water. The nurse realizes this symptom is associated with:
1. oral cancer. 2. gastric ulcers. 3. dysphagia. 4. Barrett's esophagus.
The laboring patient has been found to be having moderately strong contractions lasting 60 seconds every 3 minutes. The fetal head is presenting at a ?2 station. The cervix is 6 cm and 100% effaced
The membranes spontaneously ruptured prior to admission, and clear fluid is leaking. Fetal heart tones are in the 140s with accelerations to 150. Which nursing action has the highest priority? 1. Encourage the husband to remain in the room. 2. Keep the patient on bed rest at this time. 3. Apply an internal fetal scalp electrode. 4. Obtain a clean-catch urine specimen.
A delay in clamping the umbilical cord and keeping the baby below the level of the placenta can result in fetal:
A) anemia. B) hypovolemia. C) exsanguination. D) polycythemia.