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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This question directly addresses the impact of alcohol use on the client's work-related behaviors and performance, which is an essential aspect of their psychosocial functioning. It can provide valuable information about potential impairments in work productivity, relationships with colleagues, and overall job stability.
While the other questions are also relevant and important in assessing a client with a history of alcohol use disorder, they focus on different aspects of the client's history and treatment. For example:
B- "Do you receive treatment for any mental health disorders?" helps to assess if there are coexisting mental health issues that may be contributing to or affected by alcohol use.
C- "At what age did you begin drinking alcohol?" helps to understand the timeline of the client's alcohol use and potential early risk factors for developing alcohol use disorder.
D- "Have you received prior treatment for substance use disorder?" provides insights into the client's past attempts at addressing their alcohol use and any prior experiences with treatment.
Correct Answer is ["A","B","C","D"]
Explanation
When caring for an adolescent experiencing indications of depression, the nurse should expect the following findings:
A- Irritability: Depression can manifest as increased irritability or anger, especially in adolescents. They may become easily annoyed or frustrated.
B- Insomnia: Sleep disturbances are common in depression. Adolescents may experience difficulty falling asleep, staying asleep, or have restless and disturbed sleep.
C- Chronic pain: Depression can be associated with physical symptoms, including chronic pain. Adolescents may complain of headaches, stomachaches, or other unexplained physical discomfort.
D- Low self-esteem: Depression often involves feelings of worthlessness, guilt, and low self-esteem. Adolescents may have negative thoughts about themselves, feel inadequate, or have a distorted self-perception.
Incorrect:
E- Euphoria, on the other hand, is not a typical finding in depression. It refers to an intense state of happiness or excitement, which is not consistent with the overall mood of depression.
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