A patient is being treated on the mental health unit for an anxiety disorder. The patient approaches the nurse and reports feeling dizzy and weak, with a sensation of a racing heart. The nursing care plan includes interventions of imagery exercises and as-needed lorazepam (Ativan) for symptoms of anxiety. What should the nurse do first?
Obtain the patient's vital signs.
Give the patient the prescribed as-needed lorazepam.
Instruct the patient to sit and breathe deeply.
Instruct the patient in an imagery exercise.
The Correct Answer is A
Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.
Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.
Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.
Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: "I’m sorry if I upset you. I just wanted to make sure you’re aware of the day’s schedule."
This response may seem empathetic, but it could potentially reinforce the client's aggressive behavior. The nurse is apologizing, which might give the impression that the client's rude behavior is acceptable¹.
Choice B: "Well, if you can read it yourself, then why don’t you?"
This response is confrontational and could escalate the situation. It's important for the nurse to maintain a neutral and respectful manner.
Choice C: "You don’t have to be so rude. I’m just doing my job."
This response is defensive and could provoke further aggression from the client. It's not recommended to respond defensively to clients with borderline personality disorder¹.
Choice D: "I didn’t mean to offend you. I’ll leave the schedule here for you to review."
This is the most appropriate response. The nurse acknowledges the client's feelings without reinforcing the aggressive behavior. The nurse also respects the client's autonomy by leaving the schedule for the client to review¹.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Observing nonverbal communication is a valid nursing intervention for assessing a patient's anxiety level.
Choice B reason: Maximizing stimuli can overwhelm a patient with anxiety and is not a recommended intervention.
Choice C reason: Discouraging activities is not recommended as activities can be a form of therapy for anxiety disorders.
Choice D reason: Documenting only positive changes is not appropriate as all changes, positive or negative, should be documented for a comprehensive understanding of the patient's condition.
Choice E reason: Encouraging patients to verbalize thoughts and feelings is a therapeutic intervention that can help manage anxiety.
Choice F reason: Observing for signs of suicidal thoughts is crucial as anxiety disorders can increase the risk of suicide.
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