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
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Correct Answer is B
Explanation
A. The client will eat nutritious meals in the hospital cafeteria.
While eating nutritious meals is essential for the physical recovery of the adolescent, improving self-esteem is the highest priority in the treatment of anorexia nervosa. A negative body image and poor self-esteem are central to the disorder, and addressing these underlying psychological factors can foster more effective long-term recovery. Although ensuring the client eats is important, achieving a positive self-image is fundamental for encouraging healthier eating behaviors and overall recovery.
B. The client will verbalize feelings of a positive self-esteem.
This goal is the most appropriate because it targets the core psychological issues that contribute to anorexia nervosa, such as distorted body image and low self-worth. Enhancing the client’s self-esteem can improve their willingness to engage in healthier behaviors, including eating, which directly supports both the physical and emotional aspects of recovery. Verbalizing positive self-esteem is a key step in addressing the psychological distortions that drive the disorder.
C. The family will communicate their love and concern to the client.
While family support is vital to the recovery process, the priority should be on the adolescent’s internal psychological healing. Family communication is important for creating a supportive environment, but it is secondary to addressing the client’s self-esteem and the immediate needs of recovery from anorexia nervosa.
D. The entire family will attend family therapy sessions regularly.
Family therapy is important, but it is not the highest priority in the acute phase of treatment. In the beginning stages of treatment, the focus should be on addressing the adolescent’s psychological and nutritional needs. Family therapy can be integrated later in the treatment plan once the client’s basic physical and emotional health are stabilized.
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