A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?
Protecting the client from injury
Identifying the client's coping skills
Ensuring that the client feels safe
Determining the cause of the client's anxiety.
The Correct Answer is A
Choice A rationale:
Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale: Brittle and thin hair is a common physical manifestation of anorexia nervosa. This is due to malnutrition, which affects the health and quality of hair.
Choice B rationale: The presence of soft, unpigmented hair on the arms (and other parts of the body) is known as lanugo.
It’s a type of fine hair that the body produces in response to severe malnutrition, often seen in cases of anorexia nervosa.
The body grows lanugo in an attempt to provide insulation and maintain body heat, due to the loss of insulating body fat.
Choice C rationale: Individuals with anorexia nervosa typically have a distorted body image and often perceive themselves as overweight, even when they are underweight.
Therefore, it’s unlikely for them to comment that they are too thin and need to gain weight.
Choice D rationale: Preoccupation with thoughts about food is a common psychological symptom of anorexia nervosa. Individuals with this disorder often spend a lot of time thinking about food, dieting, and body weight.
Choice E rationale: Feeling “too tired” and lacking interest in daily workouts can be a result of the physical exhaustion and weakness caused by severe calorie restriction and malnutrition in anorexia nervosa.
Choice F rationale: The client’s report of consuming around 600 calories per day is not provided in the question. Therefore, it cannot be evaluated.
In conclusion, the nurse should expect to find brittle and thin hair, soft unpigmented hair on the arms, preoccupation with thoughts about food, and lack of energy or interest in daily activities in a client with anorexia nervosa.
Correct Answer is A
Explanation
Choice A rationale:
Antipsychotic medications are a class of drugs commonly used to treat schizophrenia and other psychotic disorders. They work by blocking dopamine receptors in the brain. However, dopamine is also involved in motor control, and blocking its receptors can lead to extrapyramidal symptoms (EPS).
EPS are a group of movement disorders that can be caused by antipsychotic medications. They include: Akathisia: A feeling of restlessness and an inability to sit still.
Dystonia: Involuntary muscle contractions that can cause twisting or spasms.
Parkinsonism: Symptoms similar to Parkinson's disease, such as tremor, rigidity, and slowness of movement. Tardive dyskinesia: Involuntary, repetitive movements of the face, tongue, or other body parts.
The risk of developing EPS is higher with older antipsychotic medications, such as haloperidol and chlorpromazine. Newer antipsychotic medications, such as risperidone and olanzapine, are less likely to cause EPS, but they can still occur.
Clients who are taking antipsychotic medications should be monitored for EPS. If EPS develop, the medication may need to be changed or the dose reduced.
Choice B rationale:
Enzymes are not known to cause EPS. They are used to treat pancreatitis by helping the body to digest food.
Choice C rationale:
Insulin is not known to cause EPS. It is used to treat type 2 diabetes mellitus by helping the body to control blood sugar levels.
Choice D rationale:
Iron supplements are not known to cause EPS. They are often taken by pregnant women to prevent iron deficiency anemia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.