A client who is experiencing a severe level of anxiety 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?

Help the client identify thoughts that may be triggers.

Explore past behaviors that have provided relief.

Attempt to distract to another focus or activity.

Speak calmly to the client stating assurance of safety.

Answer and Explanation

The Correct Answer is D

A.   Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B.   Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.
C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D.   Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

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Correct Answer is A

Explanation

A. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.

A. Shielding the client from direct sunlight when outdoors. B. Gradually withdrawing the medication over several days. C. Enforcing a fluid restriction during dosage adjustment. D. Increasing the dosage if the white blood cell count drops.

Correct Answer is ["A","B"]

Explanation

A. Shielding the client from direct sunlight is important because some antipsychotic medications, including haloperidol, can increase sensitivity to sunlight, leading to sunburn.
B. Gradually withdrawing the medication over several days is a prudent approach to avoid withdrawal symptoms and potential worsening of symptoms.
C. Enforcing a fluid restriction is not typically necessary during dosage adjustment for antipsychotic medications like haloperidol.
D. Increasing the dosage if the white blood cell count drops is not a standard practice during the dosage adjustment of antipsychotic medications. Monitoring for adverse effects and adjusting the dosage accordingly is important, but the decision should be based on a comprehensive assessment rather than a single laboratory value.

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A client who is experiencing a severe level of anxiety 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

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client’s plan of care? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

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A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

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?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?