Correct answer—A. Rationales: Families need to be encouraged to express grief in whatever way they desire, as long as they don’t harm themselves or others. The nurse’s role is to help families focus on the grief, not to alleviate it. Families need accurate information to deal with the death of a loved one. However, they must be able to listen at the time the information is given. Diazepam may cloud or even delay the grieving process.

Nursing process step: Intervention

Correct answer—A. Rationales: Using words such as dead, died, or death reinforces reality, prevents denial, and supports the grief process. Telling the family that “everything will be all right” or that “it was for the best” only minimizes their feelings. Telling the family that the client didn’t suffer is helpful but should be stated only if it’s true.

Nursing process step: Implementation

Correct answer—B. Rationales: By being able to share her feelings, the mother is acknowledging the death and beginning the work of grief. This step should begin in the ED. Making funeral arrangements and cleaning out the child’s closet aren’t short-term goals and aren’t realistic in the initial stages of grief. It isn’t desirable for the mother to leave the ED until she has had time to ask questions and to process and accept the information.

Nursing process step: Evaluation

Correct answer—C. Rationales: If the client’s physical condition is life-threatening, the priority is to treat the medical condition. Any compromise in the client’s airway, breathing, or circulation must be addressed immediately. It’s also imperative to determine the time of ingestion because it may affect treatment. The psychiatric evaluation, which includes intent to harm oneself, existence of an adequate support system, and client history, can be done after the client is medically stable.

Nursing process step: Assessment

Correct answer—C. Rationales: The responses of survivors are diverse, unpredictable, and variable depending on multiple factors. Medical jargon can be confusing, especially to a family in crisis. Speak in clear language that’s easy to understand. Providing details (such as chronology of events, circumstances of death, and treatment) can provide comfort to survivors. Whenever possible, family members should be given the option to be present during resuscitation. After efforts are ceased, the family should be allowed to view the body.

Nursing process step: Intervention

Correct answer—D. Rationales: The nurse must establish rapport and trust with the anxious client before using therapeutic touch because touching an anxious client may actually increase anxiety. Trust can be established by approaching the client in a calm and confident manner, providing a place that is quiet, safe, and private, and encouraging the client to verbalize feelings and concerns.

Nursing process step: Intervention

Correct answer—B. Rationales: A quick primary assessment is indicated on all clients in the ED. This client is a danger to himself and may have sustained other life-threatening injuries not noted by the police. The mental status examination and vital signs need to be done but aren’t the priority. Removing the restraints before fully examining the client may place both the client and the ED staff at great risk. Obtaining a urine specimen for toxicology screening takes time and shouldn’t determine the initial care.

Nursing process step: Assessment

Correct answer—C. Rationales: Ensuring the safety of the client and staff is a top priority. A client with a history of violence in the prehospital setting is at risk for violence in the emergency department. The client should be fully evaluated before restraints are removed. Suturing can be done later, and a psychiatric consult isn’t indicated until the client is medically stable. Haloperidol may be ordered after an evaluation by the physician.

Nursing process step: Intervention

Correct answer—C. Rationales: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client’s head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should be used instead of knots.

Nursing process step: Implementation

Correct answer—B. Rationales: Diphenhydramine I.M. or I.V. can quickly reverse this condition. Prochlorperazine and haloperidol are both capable of causing dystonia, not reversing it. Midazolam would make the client drowsy.

Nursing process step: Intervention

Correct answer—B. Rationales: Long wait times, as well as overcrowding, can increase the risk of violence in the ED. Working understaffed (especially during meal times) and transporting clients alone can put the staff at risk for violence. It’s important to set clear visitor policies and enforce them consistently.

Nursing process step: Analysis

Correct answer—D. Rationales: It’s the nurse’s responsibility to protect the suicidal client by providing a safe environment. Thus, suicidal clients must remain under close observation at all times. It isn’t appropriate for suicidal clients to wander around the ED alone. The nurse must ensure that a psychiatric consultation is obtained so that the client can be placed on a psychiatric hold and detained for further psychiatric evaluation. Communicating with the client and family regarding the care plan and expectations is also essential.

Nursing process step: Intervention

Correct answer—B. Rationales: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they’re ready. The reasons they stay in the relationship are complex and can be explored at a later time. The use of drugs or alcohol is irrelevant. There’s no evidence to suggest that previous victimization results in a person’s seeking or causing abusive relationships.

Nursing process step: Assessment

Correct answer—C. Rationales: These symptoms are classic symptoms of a dystonic reaction. Dystonic reactions (that is, dyskinesias) are characterized by involuntary movements of the tongue, lips, face, trunk, and extremities. Status epileptic seizures occur in greater intensity and are longer and life-threatening. Neuroleptic malignant syndrome is a rare but life-threatening reaction that involves muscle rigidity, fever, and altered mental status. Conversion disorder is the presence of physiological symptoms that have no medical explanation and are caused by a psychological conflict.

Nursing process step: Analysis

Correct answer—D. Rationales: A certified interpreter should be used if needed to conduct the interview in the client’s primary language. The encounter should be done while the client is alone, away from friends and family. A question about domestic violence can be asked on a medical history questionnaire, along with a face-to-face encounter. Questions should be direct and nonjudgmental.