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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.

Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.

Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.

Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.

A. Illusion B. Flashback C. Hallucination D. Delusion

Correct Answer is A

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.

Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.

Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.

Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

Correct Answer is A

Explanation

During general surgery, a nurse observes tachycardia, muscle rigidity, respiratory acidosis, and hyperthermia in a patient. Which complication of surgery does the nurse suspect?

A patient who repeats a word or part of a word over and over might be said to have which of the following symptoms?

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