A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.

Reinforce teaching on the client's use of coping skills

Encourage the client to use personal support systems.

Assist with a client referral for social services.

Identify if the client has thoughts of self-harm.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.

Choice B rationale:

Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.

Choice C rationale:

Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.

Choice D rationale:

Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale:

Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.

Choice B rationale:

Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.

Choice C rationale:

Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.

Choice D rationale:

Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.

Choice E rationale:

Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.

A. Administer acyclovir. B. Administer lorazepam. C. Initiate 1:1 supervision. D. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

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A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.) .

Correct Answer is ["B","C","D","E"]

Explanation

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.