A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Speak calmly to the client stating assurance of safety.

Attempt to distract to another focus or activity.

Help the client to identify thoughts that may be triggers.

Explore past behaviors that have provided relief.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Speaking calmly and assuring the client of safety is a therapeutic intervention for managing severe anxiety and panic. It helps provide a sense of reassurance and safety to the client during an acute anxious episode.

Choice B rationale: Attempting to distract the client can be helpful in some situations, but in severe anxiety, the focus should initially be on providing a sense of safety and addressing immediate distress.

Choice C rationale: Helping the client identify thoughts is more appropriate during less acute moments or in the context of cognitive-behavioral therapy. In severe anxiety, the immediate focus is on providing support and reassurance.

Choice D rationale: Exploring past behaviors may be part of a comprehensive assessment but is not the first priority during an acute episode of severe anxiety.

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Correct Answer is B

Explanation

Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.

Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.

Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.

Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.

A. "This medication may cause watery eyes and diarrhea. These will go away within 2 weeks." B. "Side effects are not likely with this type of medication. There should be no need to worry." C. "I can provide an education sheet with your discharge papers. What is your primary language?" D. "This type of medication is generally well tolerated. Tell me more about your concerns."

Correct Answer is D

Explanation

Choice A rationale: The nurse's response regarding watery eyes and diarrhea is not directly related to the client's concern about the medication's effect on blood glucose levels.

Choice B rationale: This response minimizes the potential side effects, which is not accurate. Second-generation antipsychotics are associated with metabolic side effects, including changes in blood glucose levels.

Choice C rationale: Offering an education sheet is helpful but does not directly address the client's specific concerns about the medication's impact on blood glucose levels.

Choice D rationale: This response acknowledges the client's concern, provides information about the general tolerability of the medication, and invites the client to share more about their specific worries. It encourages open communication and allows the nurse to address the client's concerns more effectively.

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A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?