A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Instruct the client to remember past coping mechanisms.

Provide a diverting activity.

Encourage verbalization of feelings.

Remain with the client.

Answer and Explanation

The Correct Answer is D

By remaining with the client, the nurse provides a sense of support and security. This presence can help alleviate the client's anxiety and provide reassurance. It also ensures that the nurse is available to assess the client's condition, offer therapeutic communication, and intervene if the anxiety escalates or the client becomes overwhelmed.

While the other options are also beneficial interventions for managing anxiety, they are not the priority in this situation. Instructing the client to remember past coping mechanisms (Option A) can be helpful, but the immediate presence of the nurse is more important to provide immediate support.

Providing a diverting activity (Option B) can be beneficial to distract the client from their anxiety, but it does not address the underlying anxiety or provide direct support.

Encouraging verbalization of feelings (Option C) is important for therapeutic communication, but it may not be the initial priority when the client is experiencing acute anxiety.

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Correct Answer is D

Explanation

This response acknowledges the client's distress and invites them to share their thoughts and feelings about the situation. It shows empathy and demonstrates active listening, allowing the nurse to gather more information about the client's emotional state and concerns. By giving the client an opportunity to express themselves, the nurse can provide appropriate support and address any guilt or self-blame the client may be experiencing.

Dismissing the client's concerns and redirecting the conversation to their partner's condition (Option A) may invalidate the client's feelings and prevent them from processing their own emotions.

Telling the client to calm down (Option B) may come across as dismissive and insensitive.

Asking the client why they think the crash is their fault (Option C) may put the client on the defensive and hinder open communication. The best approach is to actively listen to the client's concerns and create a supportive environment for them to share their feelings.

A. Hypothermia B. Hypotension C. Tremors D. Respiratory depression

Correct Answer is C

Explanation

Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.

Incorrect:

A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.

B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.

D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.

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A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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