An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?
Refer the client to the cardiology clinic.
Obtain the client's blood pressure.
Determine if alprazolam was taken recently.
Assess the client for substance abuse.
The Correct Answer is B
Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.
Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.
Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.
Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Referral to a social worker may be beneficial for long-term support and resources. However, it does not address the client’s immediate sense of fear and need for safety.
B. Offering a safe place to relax is the priority because the client is expressing fear and possible threat from a stalker. Ensuring immediate safety and reducing anxiety aligns with the priority principle of protecting the client from harm.
C. Arranging an interview with the healthcare provider is important for further evaluation and planning. However, it does not address the client’s immediate emotional distress and perceived danger.
D. Asking for details about the stalker may be part of assessment, but it should occur after the client feels safe. Gathering information is secondary to ensuring the client’s immediate safety and emotional stabilization.
Correct Answer is B
Explanation
Choice A rationale: Asking about a bad experience may provide additional information, but it does not directly address the behavioral aspect of obsessive-compulsive disorder (OCD).
Choice B rationale: This response shows empathy and curiosity and invites the client to explore their cognitive processes behind their compulsive behavior. The nurse can help the client identify and challenge their irrational or distorted thoughts that fuel their anxiety and drive them to check the locks repeatedly.
Choice C rationale: Acknowledging that repeating the same behavior helps diminish anxiety might reinforce the client's belief that checking the locks is necessary and beneficial, which could prevent them from seeking alternative coping strategies.
Choice D rationale: Stating that feelings of being driven are related to anxiety is a general observation and may not contribute to a deeper understanding of the client's experience with OCD.
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