A nurse is completing an admission assessment for a client who has obsessive- compulsive disorder and is becoming increasingly anxious. Which of the following actions should the nurse take first?
Teach the client about manifestations of anxiety.
Complete the client's assessment.
Provide reassurance of safety to the client.
Administer an anti-anxiety medication to the client.
The Correct Answer is C
Choice A rationale:
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
Choice B rationale:
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
Choice C rationale:
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
Choice D rationale:
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
Choice B rationale:
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
Choice C rationale:
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
Choice D rationale:
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
Correct Answer is C
Explanation
Choice A rationale:
Palliative care is not necessarily focused on prolonging the client's life, but rather on improving the quality of life and managing symptoms.
Choice B rationale:
Palliative care is not limited to individuals with a specific life expectancy, such as less than 6 months. It can be provided at any stage of a serious illness.
Choice C rationale:
Palliative care aims to address the physical, emotional, and psychosocial needs of both the client and their family.
Choice D rationale:
Palliative care involves a holistic approach that includes traditional medical treatments along with psychosocial and emotional support.
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