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","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.
Correct Answer is D
Explanation
In this scenario, a priority action for the nurse is to ask the client if she has considered harming her newborn. The client's symptoms of feeling "down," sadness, lack of energy, and wanting to cry raise concerns about the possibility of postpartum depression, which is a serious mental health condition that can affect new mothers. In some cases, postpartum depression can lead to thoughts of harming oneself or the newborn. Therefore, it is crucial for the nurse to assess the client's risk and ensure the safety of both the client and her baby.
Incorrect:
A- Reinforce postpartum and newborn care discharge teaching: While reinforcing postpartum and newborn care discharge teaching is an important aspect of care, it is not the priority in this situation. The client's symptoms of feeling "down," sadness, lack of energy, and wanting to cry suggest the possibility of postpartum depression. The nurse should prioritize addressing the client's emotional well-being and assessing for potential risks, rather than focusing on routine postpartum and newborn care teaching.
B- Anticipate a prescription by the provider for an antidepressant: While medication may be part of the treatment plan for postpartum depression, it is not the priority action at this stage. The nurse should first assess the client's condition, including the severity of her symptoms and any potential risk of harm to herself or her newborn. Initiating a discussion about medication can come later, in collaboration with the healthcare provider and based on a comprehensive assessment.
C- Assist the family to identify prior use of positive coping skills in family crises: While supporting the client's family and identifying positive coping skills are important, they are not the priority in this scenario. The immediate concern is addressing the client's symptoms and assessing for potential risks associated with postpartum depression. Once the client's immediate safety and emotional needs are addressed, the nurse can involve the family in the care plan and help them identify and utilize positive coping strategies.
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