The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?
Notify the registered nurse.
Raise the head of the bed.
Sit with her and listen to her concerns.
Ask the patient what is wrong.
The Correct Answer is B
Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.
Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.
Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.
Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Divorce can be a stressor, but it is not universally stressful to every individual; it depends on the person's experience and perception.
Choice B reason: Stress is subjective, and what one person finds stressful may not be stressful to another. Therefore, if the patient identifies an event as stressful, it should be considered as such.
Choice C reason: Loss of job can be a significant stressor due to financial and social implications, but again, it depends on the individual's circumstances and perception.
Choice D reason: Surgery can be a stressor due to its impact on physical health and potential for causing anxiety about medical procedures and outcomes.
Correct Answer is A
Explanation
Choice A reason: Assessing the client's level of anxiety is crucial as it can inform the nurse about the severity of the OCD symptoms and guide further interventions.
Choice B reason: Interrupting compulsive behavior abruptly can cause significant distress to the client and is not recommended without proper behavioral therapy techniques.
Choice C reason: Negative reinforcement techniques are not typically used in OCD management as they can exacerbate anxiety and are not considered therapeutic.
Choice D reason: Encouraging avoidance of anxiety-increasing situations may reinforce OCD behaviors and is not a recommended approach. Exposure and response prevention, a type of cognitive-behavioral therapy, is often used instead.
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