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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.

Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.

Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.

Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.

A. "We are here to help you and give you the care that you need right now." B. "Do you feel that you don't belong here?" C. "Try to take some deep breaths, and I'm sure you'll feel better." D. "Why do you feel that you need to leave?"

Correct Answer is A

Explanation

Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.

Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.

Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.

Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a priority when caring for a highly anxious patient?

Correct Answer is C

Explanation

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Which of the following does the nurse implement to prevent postoperative respiratory complications for a patient? (Select all that apply)

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?

Mr. G is calling out "Nurse!" When you arrive in his room, he tells you to be careful of the snake in the corner. You do not see anything in the corner. Mr. G is experiencing an:

Which of the following is a role of the LPN in the preoperative phase? Select all that apply.

We encourage the patient to cough and deep breathe after surgery to prevent:

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The muxtranks are coming. The muxtranks are coming." The nurse correctly recognizes the client's use of the word "muxtranks" as an example of which of the following alterations in speech?