A nurse is caring for a client who has been hospitalized after a motor vehicle accident. During the initial assessment, the client avoids eye contact, sits curled up in a chair, and frequently flinches when the nurse moves closer. What action should the nurse take next?
Speak calmly to the client and ask open-ended questions to assess emotional distress.
Proceed with a detailed physical assessment to rule out hidden injuries.
Contact a psychiatrist to evaluate the client's psychological state.
Encourage the client to focus on describing the events of the accident.
The correct answer focuses on addressing potential emotional or psychological distress in the client. The non-verbal cues, such as avoiding eye contact, flinching, and a defensive posture, suggest the client may be experiencing emotional trauma or fear. The nurse should approach the client calmly, use therapeutic communication, and ask open-ended questions to explore the client's feelings and provide reassurance. Conducting a physical assessment may be important later, but it does not address the immediate emotional concerns. Similarly, contacting a psychiatrist prematurely or pressuring the client to describe the events of the accident might exacerbate their distress without first establishing trust and comfort.
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NCLEX RN
Psychosocial Integrity
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