Mr. L, who has a severe fear of needles, is hospitalized on your medical unit. The laboratory technician enters to draw blood for the routine CBC, and Mr. L begins to cry out, "Get away from me! I can't breathe! I'm having a heart attack!" What should be your first response to Mr. L?
"Relax. Take a few deep breaths. I'll stay with you."
"I'll take your vital signs and call my supervisor."
"Don't worry. She's done this many times before."
"Why do you think you're having a heart attack, Mr. L?"
The Correct Answer is A
Choice A reason: This response is calming and supportive. It addresses Mr. L's immediate distress by providing reassurance and a directive that can help him manage his panic, which is essential in a situation where a patient is experiencing extreme anxiety.
Choice B reason: While taking vital signs is an important step, it should not be the first response. The priority is to address the patient's acute distress and provide reassurance.
Choice C reason: This response minimizes the patient's feelings and does not address his immediate fear or offer any comfort or support.
Choice D reason: Asking why he thinks he's having a heart attack could increase his anxiety. It's important to first calm the patient before attempting to rationalize the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: For a client with borderline personality disorder, the priority is to ensure safety, which includes protecting them from self-harm behavior, as they may have impulsive tendencies that can lead to self-injury.
Choice B reason: While providing strategies for redirecting violent behavior is important, it is secondary to ensuring the client's immediate safety.
Choice C reason: Exploring reasons for behavior is a therapeutic intervention that can help in the long term but is not the immediate priority.
Choice D reason: Encouraging the client to talk about their feelings is part of ongoing therapy but does not take precedence over ensuring the client's safety.
Correct Answer is D
Explanation
Choice A reason: Legs in adduction can increase the risk of dislocation after hip replacement surgery.
Choice B reason: Flexing the hip more than 90 degrees can also increase the risk of dislocation.
Choice C reason: Internal rotation of the leg can lead to dislocation of the new hip joint.
Choice D reason: Maintaining the legs in abduction helps to stabilize the hip and prevent dislocation.
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