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

Informed consent is an essential ethical principle in healthcare, including mental health treatment. Even if the client has previously signed a consent form for electroconvulsive therapy (ECT), they have the right to change their mind and refuse the treatment at anytime. Respecting the client's autonomy and their right to make decisions about their own healthcare is crucial.

The nurse's response should support the client's right to refuse the treatment, rather than attempting to persuade or convince them otherwise. It is important to provide information, answer questions, and discuss the client's concerns or reasons for refusing the treatment. The client's decision should be respected and further discussions can be held with the healthcare provider to explore alternative treatment options or address any concerns the client may have.

A- "You have given signed consent for the treatments after they were explained to you." - This response does not acknowledge the client's right to refuse the treatment. Even if the client previously provided consent, they still have the right to change their mind and refuse the treatment. Informed consent is an ongoing process, and the client's autonomy should be respected throughout their care.

B- "You can refuse them, but the provider believes they are necessary." - While it may be true that the healthcare provider believes ECT is necessary, this response does not fully acknowledge the client's autonomy. It is important to emphasize the client's right to make decisions about their own healthcare, independent of the provider's opinion. The decision to refuse or accept the treatment should ultimately be made by the client.

C- "You will feel better after the course of treatments." - This response does not address the client's concerns or their right to refuse the treatment. It is essential to respect the client's autonomy and their ability to make decisions about their own care, even if their decision may not align with the potential benefits of the treatment. The nurse should focus on providing information, addressing the client's concerns, and supporting their decision-making process.

A. Anxiety and diaphoresis B. Muscle aches and chills C. Fatigue and depression D. Arrhythmia and respiratory depression

Correct Answer is A

Explanation

Anxiety and diaphoresis: Alcohol withdrawal commonly presents with symptoms of anxiety, restlessness, and excessive sweating (diaphoresis). These symptoms are due to the central nervous system's hyperactivity caused by the sudden cessation of alcohol intake.

Incorrect:

B- Muscle aches and chills: Muscle aches and chills are not typical manifestations of alcohol withdrawal. These symptoms are more commonly associated with opioid withdrawal rather than alcohol withdrawal.

C- Fatigue and depression: Fatigue and depression are common symptoms during alcohol withdrawal. The client may feel tired, lack energy, and experience a low mood due to the neurochemical imbalances that occur during withdrawal.

D- Arrhythmia and respiratory depression: While alcohol withdrawal can lead to some cardiovascular and respiratory symptoms, such as increased heart rate and blood pressure, severe arrhythmia and respiratory depression are not typical findings. These more severe symptoms may indicate a more severe withdrawal syndrome or coexisting medical conditions that require immediate medical attention.

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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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Explanation

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Correct Answer is A

Explanation

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