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) Diarrhea: Metabolic alkalosis is more likely to be associated with constipation rather than diarrhea. Diarrhea is typically a cause of metabolic acidosis due to the loss of bicarbonate in stool, rather than a result of metabolic alkalosis.

B) Bradycardia: Bradycardia is not a typical manifestation of metabolic alkalosis. Alkalosis can lead to arrhythmias, but it generally does not cause a slow heart rate. Instead, tachycardia might occur as the body compensates for the altered acid-base balance.

C) Tinnitus: Tinnitus is not a common symptom of metabolic alkalosis. It is more often associated with aspirin toxicity or other conditions affecting the auditory system, rather than changes in acid-base balance.

D) Tetany: Tetany is a common manifestation of metabolic alkalosis. The alkalosis causes a decrease in ionized calcium levels, which increases neuromuscular excitability and can lead to muscle cramps, spasms, and tetany. This is a key sign for nurses to monitor as it indicates significant electrolyte disturbances associated with the alkalotic state.

A. Cleanse the client's finger with an antiseptic swab. B. Hold the client's finger in a dependent position. C. Wipe away the first drop of blood. D. Place the lancet on the side of the selected finger.

Correct Answer is A

Explanation

A) Cleanse the client's finger with an antiseptic swab: The first step in performing a capillary blood glucose test is to cleanse the client’s finger with an antiseptic swab. This reduces the risk of infection and ensures that any contaminants on the skin do not affect the accuracy of the blood glucose reading.

B) Hold the client's finger in a dependent position: Holding the finger in a dependent position can help increase blood flow, but this step is taken after cleansing the finger. The priority is to first clean the area to minimize the risk of infection.

C) Wipe away the first drop of blood: Wiping away the first drop of blood is done to avoid contamination from interstitial fluid and to ensure a more accurate reading. However, this action occurs after the blood sample is obtained, not before the test begins.

D) Place the lancet on the side of the selected finger: While placing the lancet on the side of the finger is important for minimizing discomfort and obtaining an adequate blood sample, it follows the initial steps of cleaning the finger and preparing for the blood draw.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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