A highly intoxicated client is brought to the emergency department. Paramedics report that the client was violent during transport and tried to kick the door out of the ambulance
How should the nurse prepare before seeing this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Remove any hemostats from the pocket.
2. Take off the stethoscope and place it in the pocket.
3. Ask the paramedics to place the client in leather restraints.
4. Enter the room calmly, with a smile.
5. Give the client 20 minutes or so to calm down before the assessment begins.
1,2,4
Rationale 1: The nurse should remove any potential weapons.
Rationale 2: A stethoscope hung around the neck is a convenient "handle" for anyone who would like to gain control of the nurse.
Rationale 3: The nurse should not ask the paramedics to perform this intervention.
Rationale 4: Being calm and pleasant can help defuse potentially violent situations.
Rationale 5: The nurse should not wait 20 minutes to see a client who is highly intoxicated.
Global Rationale:
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