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.

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Correct Answer is C

Explanation

Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.

Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.

Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.

Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.

Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.

A. "Following a blood spill. I should use a bleach solution with a ratio of 1 to 20." B. "Soiled dressings should be placed in a biohazard trash receptacle." C. "For a client who has Clostridium difficile. I will cleanse my hands with an alcohol-based rub." D. "Droplet precautions require that I wear a gown and gloves when providing client care."

Correct Answer is B

Explanation

Soiled dressings, which may contain infectious materials, should be disposed of in a biohazardous waste container to prevent the spread of infection.

According to standard precautions, a 1:10 bleach solution (1 part bleach to 10 parts water) is recommended for cleaning up blood spills.

Alcohol-based hand rubs are not effective against Clostridium difficile. Handwashing with soap and water is necessary to remove the spores.

Droplet precautions typically require wearing a surgical mask, not a gown and gloves. Gowns and gloves are used in contact precautions.

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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

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Correct Answer is B

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