A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Encourage verbalization of feelings.

Provide an activity for diversion.

Remain with the client.

Have the client identify two coping skills.

Answer and Explanation

The Correct Answer is C

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

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Correct Answer is A

Explanation

Answer: A

Rationale:

A) "It must be very difficult for you to see your wife in pain.": This response acknowledges the partner's feelings and provides emotional support. It shows empathy and validates the partner's experience, helping to build rapport and trust between the nurse and the family member.

B) "I wish there was more that I could do to relieve your wife's pain, too.": While this response expresses sympathy, it might unintentionally convey a sense of helplessness or inadequacy on the part of the nurse, which could increase the partner's anxiety or frustration.

C) "I'm sure your wife will begin to feel better soon.": This response is intended to be reassuring, but it can come off as dismissive of the partner's current concern and may not address their immediate emotional needs. It also makes a promise that the nurse cannot guarantee.

D) "We're doing everything we can to keep your wife comfortable.": This response provides factual information about the care being provided, but it does not address the partner's emotional distress. It focuses on the actions of the healthcare team rather than acknowledging the partner's feelings.

A. Amnesia. B. Tachycardia. C. Altered level of consciousness. D. Hypotension.

Correct Answer is C

Explanation

Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.

Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.

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A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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