A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?
Recommend that the client talk with a social worker today.
Offer the client a safe place to relax before the Interview.
Assure client of an interview with the healthcare provider today.
Ask the client to describe the stalker and If It is frequent.
The Correct Answer is B
Choice A Rationale: While talking to a social worker could be beneficial, it may not address the client's immediate need for safety and comfort. Social work intervention is important, but the priority is to ensure the client feels secure in the current environment.
Choice B Rationale: Offering a safe place to relax is crucial as it addresses the client's immediate need for safety and security. Feeling safe can help reduce anxiety and allows the client to compose themselves before discussing their concerns in detail.
Choice C Rationale: Assuring an interview with the healthcare provider is important, but it does not prioritize the client's immediate emotional and psychological needs. The assurance of care is part of the overall treatment plan but is secondary to providing a safe environment.
Choice D Rationale: Asking the client to describe the stalker is part of the assessment process, but it is not the most important initial action. The client's immediate emotional state must be stabilized before any detailed information gathering can be effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Alkaline phosphatase is not typically associated with the monitoring of lithium therapy. The primary concern is renal function.
Choice B rationale: Blood glucose is not the most critical parameter to monitor before initiating lithium therapy. The focus is on renal function.
Choice C rationale: White blood count is not the primary laboratory value to assess before starting lithium. Renal function is more critical.
Choice D rationale: Serum creatinine is the most important laboratory finding to review before beginning lithium therapy. Lithium is primarily excreted by the kidneys, and impaired renal function can lead to lithium toxicity. Regular monitoring of renal function, including serum creatinine levels, is crucial to prevent adverse effects.
Correct Answer is A
Explanation
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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