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
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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Related Questions
Correct Answer is D
Explanation
A. Room number of the client:
- The room number alone is not sufficient for accurate client identification. Room numbers may change, and multiple clients may share the same room. Relying on the room number alone can lead to errors.
B. Client's telephone number:
- The client's telephone number is not typically used as a primary identifier for medication administration. It may be part of the client's record, but it is not the primary means of confirming identity before administering medications.
C. Client's full medical diagnosis:
- While the client's medical diagnosis is important for understanding their overall health condition, it is not a primary identifier for medication administration. Diagnoses can be complex and may not be unique to a single individual within a healthcare setting.
D. Name of the client:
- Matching the client's name with their identification band or other official records is a crucial step in preventing medication errors and ensuring the right medication is given to the right person.
Correct Answer is A
Explanation
a. "I should discuss this document with my family after I sign it"
Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.
b. "I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.
c. "An atorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.
d. "My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.
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