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 A

Explanation

A) Consume a diet low in cholesterol: A diet low in cholesterol is beneficial for preventing cholelithiasis (gallstones), as high cholesterol levels can contribute to the formation of cholesterol stones in the gallbladder. By reducing dietary cholesterol, the risk of gallstone formation can be minimized.

B) Increase your intake of refined carbohydrates: Increasing the intake of refined carbohydrates can lead to higher levels of triglycerides and cholesterol in the blood, which can promote the formation of gallstones. This dietary change is not recommended for preventing cholelithiasis.

C) Consume a diet high in calories: A high-calorie diet, especially if it leads to obesity, increases the risk of developing gallstones. Obesity is a significant risk factor for cholelithiasis, and a high-calorie diet can contribute to weight gain and the development of gallstones.

D) Reduce your dietary fiber intake: Dietary fiber helps in reducing cholesterol levels by binding bile acids in the intestines, which in turn can prevent the formation of cholesterol gallstones. Reducing fiber intake would be counterproductive and increase the risk of cholelithiasis.

A. Administer risperidone 25 mg IM. B. Teach the client how to perform guided imagery. C. Stay with the client until the panic attack subsides. D. Encourage the client to take quick, shallow breaths.

Correct Answer is C

Explanation

A) Administering risperidone 25 mg IM is not typically appropriate for treating a panic attack. Risperidone is an antipsychotic medication used for treating conditions like schizophrenia and bipolar disorder, not for the immediate management of panic attacks. Immediate pharmacological intervention is not generally the first line of treatment in acute panic attacks unless the client has a specific medication prescribed for such episodes.

B) Teaching the client how to perform guided imagery can be beneficial for long-term anxiety management but is not the most effective intervention during an acute panic attack. During a panic attack, the client's ability to focus and learn new techniques may be impaired, making it less effective in the immediate situation.

C) Staying with the client until the panic attack subsides is the most appropriate action. Presence and reassurance from the nurse can help the client feel safer and more grounded. This approach provides emotional support and can help reduce the severity and duration of the panic attack by addressing the client's immediate need for security and stability.

D) Encouraging the client to take quick, shallow breaths can exacerbate hyperventilation and increase anxiety during a panic attack. Instead, slow, deep breathing techniques are recommended to help calm the client's physiological response and reduce the intensity of the panic attack.

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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

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Correct Answer is C

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