A nurse is caring for a client who is has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the floor continually. Which of the following actions should the nurse take first?
Tell the client you will remain with her.
Take the client to a quiet room.
Ask the client what precipitated this anxiety
offer the client a prescribed anxiety medication
The Correct Answer is A
A: The client is exhibiting severe anxiety (hyperventilation, pacing, inability to focus). The priority intervention is to stay with the client and provide a calm, reassuring presence, which helps reduce anxiety and promotes a sense of safety. Presence is the foundation before any further interventions.
B: While taking the client to a quiet room can be helpful, the first action should be to reassure her of your presence and support.
C: Inquiring about the cause of anxiety can be useful, but it should not be the first step when the client is actively hyperventilating.
D: Medication might be necessary, but initial reassurance and creating a safe environment take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: SSRIs are often the first-line treatment for depression in older adults due to a favorable side effect profile compared to other antidepressants.
B: Benzodiazepines are not typically used as they can increase the risk of falls and confusion.
C: Hypnotics are used for sleep issues but are not antidepressants.
D: Monoamine oxidase inhibitors are effective but often reserved for cases where other treatments have failed due to their dietary restrictions and side effects.
Correct Answer is B
Explanation
A: While mental illness could be a risk, social isolation is a more direct and immediate risk given the scenario.
B: Geographical and population factors contributing to a lack of social interaction directly suggest social isolation.
C: Substance abuse might develop as a coping mechanism but is not the most immediate risk.
D: Depression could be a consequence of social isolation, but the primary risk here is the isolation itself.
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