A highly intoxicated client is brought to the emergency ...

[daltonest1984]

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.

Question 2

Two nurses are in the day room when a visitor approaches and starts yelling about the care his mother is receiving. One nurse says, I'm sorry you are upset. What can I do for you? The visitor continues to complain more loudly.
 
  What should the other nurse do? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. Quietly direct other people out of the room.
  2. Leave the room and call security.
  3. Say, Who are you?
  4. Move toward the visitor and say, Keep your voice down.
  5. Stay next to the other nurse.

[ryrychapman11]

Answer to Question 1

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:

Answer to Question 2

1,2
Rationale 1: Isolating a person who is angry and aggressive helps by taking away part of the audience. This is also a strategy to protect others.
Rationale 2: It may be that the visitor is just upset and will calm down quickly with the other nurse's verbal intervention, but that is not assured.
Rationale 3: This question may further infuriate the visitor because the nurses don't know him or his mother. Also, one nurse should carry the conversation.
Rationale 4: The nurse should not make a move toward the visitor or demean him.
Rationale 5: The nurse should move away and out of the room to call security.
Global Rationale: