A nurse is caring for a client who is experiencing anxiety. When using clinical decision making, which of the following actions should the nurse take first?
Measure the client's manifestations using an anxiety rating scale.
Initiate a referral to a local support group.
Assist in finding alternative ways to cope.
Administer an antianxiety medication.
The Correct Answer is A
A) Measure the client's manifestations using an anxiety rating scale: This action is essential as the first step because it allows the nurse to accurately assess the severity of the client's anxiety. Understanding the level of anxiety helps in planning appropriate interventions and monitoring the effectiveness of any treatment provided. Accurate assessment is foundational in clinical decision making.
B) Initiate a referral to a local support group: While beneficial, referring the client to a support group should follow an initial assessment. Support groups can offer long-term benefits, but immediate needs and severity must be evaluated first.
C) Assist in finding alternative ways to cope: Helping the client develop coping strategies is an important intervention. However, before suggesting specific coping mechanisms, the nurse needs to understand the current level of anxiety and how it affects the client. This ensures that the coping strategies are appropriately tailored.
D) Administer an antianxiety medication: Administering medication can be crucial in managing severe anxiety, but this step should come after a thorough assessment. The nurse needs to determine if medication is necessary and what dosage might be appropriate, based on the anxiety rating scale and other assessment findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) "Drink whole milk instead of skim milk": Whole milk contains higher levels of saturated fats compared to skim milk. For individuals with hyperlipidemia, it is advisable to reduce intake of saturated fats to help lower cholesterol levels and improve heart health. Drinking skim or low-fat milk is a healthier option to manage lipid levels.
B) "Limit saturated fat to 15 percent of total daily fat intake": The American Heart Association recommends that saturated fat intake should be limited to less than 7% of total daily calories for those managing hyperlipidemia. Limiting saturated fat to 15% is too high and can contribute to increased cholesterol levels, negatively impacting cardiovascular health.
C) "Select trans fats for daily fat intake": Trans fats are known to significantly raise LDL (bad) cholesterol levels and lower HDL (good) cholesterol, increasing the risk of heart disease. It is essential to avoid trans fats altogether in the diet, as they are detrimental to cardiovascular health.
D) "Replace red meat with fish three times per week": Replacing red meat with fish, especially fatty fish like salmon, mackerel, and sardines, can be beneficial for individuals with hyperlipidemia. Fish is a good source of omega-3 fatty acids, which can help lower triglyceride levels, reduce inflammation, and improve overall heart health. This dietary change supports better lipid management and reduces the risk of cardiovascular diseases.
Correct Answer is D
Explanation
A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.
B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.
C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.
D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.
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