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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Take a tub bath every other day using a mild soap: While maintaining hygiene is important, taking a tub bath is not the most effective way to prevent the spread of MRSA. Showering is usually recommended to help wash away bacteria without sitting in potentially contaminated water.
B) Wash bathroom surfaces daily with isopropyl alcohol: Cleaning surfaces regularly is important, but using isopropyl alcohol specifically for this purpose is not necessary. Household disinfectants that are effective against bacteria, including bleach solutions, can be used to disinfect surfaces.
C) Place the soiled dressing in a sealed plastic bag before placing it in the trash can: This instruction is crucial to prevent the spread of MRSA. Properly containing and disposing of contaminated dressings minimizes the risk of bacteria spreading to other surfaces or individuals.
D) Wash the wound area before washing the surrounding skin: When cleaning wounds, it's typically recommended to clean the surrounding skin first to avoid spreading bacteria from the wound to the clean skin. This reduces the risk of contamination and helps maintain a sterile environment around the wound.
Correct Answer is D
Explanation
A) Expect optimum visual acuity to return in 4 to 6 weeks: While some improvement in vision can be noted soon after cataract surgery, optimal visual acuity typically returns within 1 to 2 months. It's important to set realistic expectations for recovery. Telling the patient to expect optimum visual acuity to return in 4 to 6 weeks provides a more accurate timeframe for complete visual recovery.
B) Notify the provider if new floaters persist for more than 3 days: The presence of new floaters can be a sign of complications such as retinal detachment or vitreous hemorrhage. However, patients are generally advised to notify their provider immediately if they notice any new floaters, flashes of light, or a sudden decrease in vision, rather than waiting for three days. Immediate notification can lead to prompt evaluation and treatment if necessary.
C) Take aspirin every 4 to 6 hr for mild discomfort: Aspirin is generally avoided postoperatively due to its blood-thinning properties, which can increase the risk of bleeding. Instead, non-aspirin pain relievers like acetaminophen are usually recommended to manage mild discomfort after cataract surgery, as they do not carry the same risk of bleeding complications.
D) Avoid lifting objects that weigh 9.07 kg (20 lb) or more: Patients are advised to avoid lifting heavy objects and engaging in strenuous activities after cataract surgery to prevent increased intraocular pressure, which can interfere with healing and potentially cause complications such as bleeding or dislocation of the intraocular lens. This instruction helps ensure the safety and proper healing of the surgical site.
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