A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Administer an anti-anxiety medication.

Explore behaviors that have helped to reduce the client's anxiety in the past.

Minimize environmental stimuli in the client's surroundings.

Explain to the client that anxiety causes physical manifestations

Answer and Explanation

The Correct Answer is C

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.

Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.

Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.

Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.

A. Oxygen saturation 90% B. Respiratory rate 20/min C. Apical pulse rate 88/min D. Oral temperature 37.6° C (99.7° F)

Correct Answer is A

Explanation

An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.

The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.

However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 12 hr postoperative following intestinal surgery. Which of the following findings should the nurse report to the charge nurse prior to client ambulation?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is at 12 weeks of gestation and has hyperemesis gravidarum. Which of the following client statements indicates an understanding of the nurse's instructions?

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

A nurse is assisting with a prenatal examination of a client who is at 8 weeks of gestation. The nurse notes that the client's vagina and vulva are a purplish color. The nurse should document this finding as which of the following?

A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching to a newly licensed nurse about bowel sounds. Which of the following characteristics should the nurse use to describe hyperactive bowel sounds?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse eﬀect of the treatment?

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?