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 reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.
Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.
Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.
Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.
Correct Answer is C
Explanation
Choice A reason: Borderline personality disorder is characterized by instability in relationships, self-image, and emotions, not necessarily by being pouty and demanding attention.
Choice B reason: Schizoid personality disorder involves detachment from social relationships and a limited range of emotional expression, which does not align with the patient's behavior.
Choice C reason: Narcissistic personality disorder includes traits such as needing excessive admiration and having a sense of entitlement, which could explain the patient's behavior.
Choice D reason: Antisocial personality disorder is marked by a disregard for and violation of the rights of others, which is not described in the patient's behavior.
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