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.
Encourage the client to focus on describing the events of the accident.
Contact a psychiatrist to evaluate the client's psychological state.
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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