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 A
Explanation
Choice A rationale:
Genital herpes can be transmitted through viral shedding even when there are no visible lesions.
Choice B rationale:
Oil-based lubricants can weaken latex condoms, increasing the risk of condom breakage.
Choice C rationale:
Maintaining hydration is important during outbreaks to support the body's immune response.
Choice D rationale:
Acyclovir can help manage outbreaks, but it does not cure the infection.
Correct Answer is D
Explanation
Choice A rationale:
Holding the fork through the entire meal can lead to mindless eating and overeating. The client should put down the fork between bites and chew slowly to savor the food and feel full faster.
Choice B rationale:
Planning meals day by day can be stressful and impractical for the client. The client might not have enough time or resources to prepare healthy meals every day, or might be tempted by unhealthy options when hungry. The client should plan meals ahead of time, such as weekly or monthly, and stock up on nutritious foods that are easy to prepare.
Choice C rationale:
Scheduling three times to eat each day can be too rigid and unrealistic for the client. The client might not feel hungry at the scheduled times, or might feel hungry in between meals and snack
on junk food. The client should listen to their body and eat when they are hungry, but not too hungry. The client should also eat slowly and stop when they are full, but not too full.
Choice D rationale:
Eating off a smaller plate can help reduce the portion size and calorie intake of the client. This is a simple and effective way to manage obesity without feeling deprived or hungry. A smaller plate can also create an illusion of having more food, which can increase the satisfaction of the meal.
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