The nurse is assessing a nervous 18-year-old patient who has vital signs of P 120, R 30, and BP 160/90. The patient states that he feels something bad is about to happen. Based on this data alone, how should the nurse identify the patient's level of anxiety?
Moderate
Panic
Mild
Severe
The Correct Answer is D
A. Moderate: Moderate anxiety typically involves increased alertness and focus, not severe physiological changes.
B. Panic: Panic is characterized by extreme dread and inability to function, often with a sense of unreality.
C. Mild: Mild anxiety involves slight discomfort and can enhance learning and performance.
D. Severe: Severe anxiety includes significant physiological responses (elevated vital signs) and a sense of impending doom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Every 6 months. Semi-annual screenings may be necessary for certain conditions or if there are ongoing health issues, but generally, an annual check-up is sufficient for preventive health.
B. Every 3 years. This interval is too long for preventive health screenings in older adults, who are at higher risk for various health conditions.
C. Every 2 years. This interval may be appropriate for certain screenings, but annual check-ups are recommended to ensure timely detection and management of health issues.
D. Every year. Annual health screenings are recommended for older adults to monitor for chronic conditions, update vaccinations, and promote overall health.
Correct Answer is F
Explanation
A. Insert nasogastric tube: A nasogastric tube may be inserted early to prevent aspiration and manage gastric distension.
B. Initiate fluid therapy: Fluid therapy is crucial and initiated early to combat hypovolemic shock.
C. Insert Foley catheter: A Foley catheter is often inserted early to monitor urine output and assess renal function.
D. Establish airway: Establishing an airway is the highest priority intervention for burn victims, especially if there are signs of inhalation injury.
E. Administer analgesics: Pain management is crucial but is initiated early in the treatment process.
F. Tetanus prophylaxis: Tetanus prophylaxis is important to prevent infection but is typically administered after the immediate life-threatening issues have been addressed.
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