A patient admitted to the critical care unit for gastrointestinal hemorrhage reports feeling tense and nervous. The nurse notes the patient appears restless with increased blood pressure and pulse. If the physical assessment shows no other changes, it is most important for the nurse to take which action?A. Give prescribed IV dose of lorazepam (Ativan).B. Stay with the patient and encourage expression of concerns.C. Ask a family member to remain at the bedside with the patient.D. Teach the patient how to use guided imagery to reduce anxiety.
B. Stay with the patient and encourage expression of concernsAnxiety is a common problem for critically ill patients. The nurse should first stay with the patient and encourage the patient to express concerns and needs. After expression of feelings, the nurse should determine the appropriate intervention if needed (e.g., lorazepam, guided imagery, family presence). In addition, staying with the patient will allow the nurse to continue to assess for physiologic changes associated with recurrent gastrointestinal bleeding.
B. Stay with the patient and encourage expression of concerns.
Explanation: The patient’s symptoms suggest they may be experiencing anxiety, and it is important for the nurse to be present and provide support. Encouraging the patient to express their concerns can often alleviate anxiety by allowing the patient to verbalize their fears and worries. Administering medication such as lorazepam should be avoided unless absolutely necessary, as it can further depress respiratory function and cause other adverse effects. Asking a family member to stay with the patient can be helpful, but the nurse should still remain present and actively involved in the patient’s care. Teaching the patient how to use guided imagery may be beneficial, but it should be done after the patient’s anxiety has been addressed and they are in a more receptive state.
More Answers:
Understanding Capillary Refill Time: Importance & Emergency Intervention for Poor Circulation in the HandImprovement in Heart Failure: How Pulmonary Artery Wedge Pressure Can Indicate Progress
Enhancing Lung Function: Importance of Positive End-Expiratory Pressure (PEEP) in Preventing Alveolar Collapse