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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "The client is preoccupied with a supposed body defect.": This manifestation is more characteristic of body dysmorphic disorder rather than generalized anxiety disorder (GAD).

B. "The client compulsively bites fingernails.": Nail-biting is often associated with obsessive-compulsive disorder (OCD) or other stress-related behaviors rather than GAD.

C. "The client exhibits hoarding behaviors.": Hoarding is typically associated with obsessive-compulsive disorder (OCD) and not generalized anxiety disorder.

D. "The client puts off making decisions.": Individuals with generalized anxiety disorder often experience indecisiveness and procrastination due to excessive worry and fear of making the wrong choice. This is a common manifestation of GAD

A. Muscle twitching B. Bounding pulse C. Hypertension D. Decreased bowel sounds

Correct Answer is A

Explanation

A) Muscle twitching:
Muscle twitching, also known as tetany, is a common manifestation of hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to symptoms such as muscle cramps, spasms, and twitching. This is a key clinical sign that helps in diagnosing hypocalcemia.
B) Bounding pulse:
A bounding pulse is not typically associated with hypocalcemia. Instead, it is more often seen in conditions such as fluid overload or hyperdynamic circulatory states, where there is increased cardiac output or vascular volume.
C) Hypertension:
Hypertension is not a common manifestation of hypocalcemia. Hypocalcemia is more likely to cause hypotension due to its effect on cardiac contractility and vascular tone, rather than causing high blood pressure.
D) Decreased bowel sounds:
Decreased bowel sounds are not commonly associated with hypocalcemia. Hypocalcemia affects neuromuscular function, but it typically causes increased gastrointestinal motility rather than decreased motility, which would lead to hyperactive bowel sounds rather than decreased ones.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record for a client who has generalized anxiety disorder. Which of the following manifestations should the nurse expect to see included in the client's medical record?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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