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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Developing influenza after receiving the vaccine the previous year is not a contraindication for receiving the vaccine this year. In fact, the vaccine is recommended annually.

Choice B rationale:

Hypertension is not a contraindication for receiving the influenza vaccine.

Choice C rationale:

Clients with a history of Guillain-Barré syndrome should generally avoid receiving the influenza vaccine due to a potential increased risk of recurrence of the syndrome.

Choice D rationale:

Allergies to dairy products are not a contraindication for receiving the influenza vaccine.

A. Slurred speech B. Yellowed sclera C. Ulcers on the ankles D. Swelling in the joints

Correct Answer is A

Explanation

Choice A rationale:

Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.

Choice B rationale:

Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.

Choice C rationale:

Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.

Choice D rationale:

Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer the influenza vaccine to a group of clients. For which of the following clients should the nurse withhold the vaccine?

Correct Answer is C

Explanation

A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?

Correct Answer is A

Explanation

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