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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
"I know you will do well living out in the community.". When a client expresses feelings of gratitude towards a nurse as they are about to be discharged, they are mostly affirming the therapeutic relationship between both parties. The nurse should acknowledge this affirmation clearly, warmly, and humbly, while encouraging the client's progress and independence. Choice D, "I know you will do well living out in the community" acknowledges the client's progress and offers encouragement.
Choice A, "Aren't you excited about being discharged today?" is a closed question that does not encourage the client's progress.
Choice B, "How do you feel about being discharged?" is not the best response because it is too broad.
Choice C, "I will send you a note in a few weeks" does not offer affirmation and encouragement to the client.
Correct Answer is B
Explanation
When a patient with heart failure begins treatment with an ACE inhibitor, the nurse should prioritize monitoring the patient's blood pressure because ACE inhibitors can cause hypotension. Oxygen saturation, choice A, may be important to monitor in some cases, but it is not the priority in this situation. Level of consciousness, choice C, and assessment for nausea, choice D, may also be important but are not the priority assessments in this situation.
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