A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Identifying the client's coping skills.

Protecting the client from injury to himself.

Determining the cause of the client's anxiety.

Ensuring that the client feels safe.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Misplacing car keys is a common occurrence in many people's lives and is not necessarily indicative of Alzheimer's disease. It can happen to anyone due to various factors like stress or distraction.

Choice B rationale:

Difficulty performing familiar tasks is a potential early warning sign of Alzheimer's disease. This can include tasks that the person previously did with ease, such as cooking or dressing themselves. Alzheimer's disease affects cognitive abilities, including the ability to perform familiar tasks.

Choice C rationale:

Losing sense of time is another potential early warning sign of Alzheimer's disease. People with Alzheimer's may lose track of days or seasons, as the disease impacts their sense of time and memory.

Choice D rationale:

Problems with performing basic calculations can be a sign of cognitive decline, but it is not one of the primary early warning signs of Alzheimer's disease. This choice is less specific to Alzheimer's and could be related to other cognitive disorders as well.

Choice E rationale:

Becoming lost in a usually familiar environment is a significant early warning sign of Alzheimer's disease. Individuals with Alzheimer's may become disoriented even in places they know well, leading to confusion and anxiety. This is a result of the disease affecting their spatial memory and navigation skills.

A. "You will need to take this medication on an empty stomach.” B. "You will need to consume a low-salt diet while on this medication.” C. "You will need your blood levels drawn weekly during the first month.” D. "You will need to stop this medication if you develop severe diarrhea.”

Correct Answer is C

Explanation

Choice A rationale:

Ingesting lithium (Eskalith) on an empty stomach can lead to gastrointestinal upset. Therefore, clients are generally advised to take this medication with food or milk to minimize these side effects. This choice is incorrect.

Choice B rationale:

While sodium intake can impact lithium levels, clients are usually advised to maintain a consistent, moderate sodium intake rather than adopting a low-salt diet. Extreme dietary changes can affect lithium levels and potentially lead to toxicity, making this choice inaccurate.

Choice C rationale:

Monitoring blood levels of lithium is crucial to ensure therapeutic effectiveness and prevent toxicity. During the initiation phase, frequent monitoring, typically weekly, is necessary to establish the appropriate dosage for each individual. Lithium has a narrow therapeutic range, and blood levels need to be closely regulated.

Choice D rationale:

Discontinuing lithium abruptly can lead to worsened bipolar symptoms. Diarrhea can contribute to dehydration and electrolyte imbalances, potentially impacting lithium levels, but stopping the medication is not the initial action to take. Adjustments in dosage or management strategies are usually explored before considering discontinuation.

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A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is C

Explanation

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