6) The medical-surgical nurse is performing a nursing assessment on Tyquan, a 43

6) The medical-surgical nurse is performing a nursing assessment on Tyquan, a 43 year old post-stroke patient who is acutely confused. Tyquan becomes verbally threatening, believing that “all you women are trying to put me back in the war”. The nurse attempts to verbally calm him, but he continues to escalate and gets out of bed swinging his arms. There are no other staff or visitors present in the room.
What nursing interventions are indicated?
What medical complications could result if Tyquan’s agitation continues to increase?
How does the nurse act to ensure his/her own safety, as well as the safety of the patient?
7) A woman, Nina, presents to the Emergency Department via a male companion due to heavy vaginal bleeding. She does not speak English fluently, and her male companion speaks for her. She is disheveled with bags under her eyes. She does not appear to know what city she is in.
As the nurse, do you have any concerns?
How would you go about completing a mental status exam and physical exam on the patient?
What are the legal and ethical responsibilities of the nurse?