A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Help the client identify thoughts that may be triggers.

Explore past behaviors that have provided relief.

Attempt to distract to another focus or activity.

Speak calmly to the client stating assurance of safety.

Answer and Explanation

The Correct Answer is D

A.   Identifying triggers may be beneficial, but the client is currently in a state of severe anxiety, and immediate intervention to address the symptoms is needed.
B.   Exploring past behaviors can be addressed later; the immediate focus should be on managing the acute symptoms of anxiety.
C. Attempting to distract the client can be helpful, but providing reassurance and addressing safety concerns take precedence.
D.   Speaking calmly to the client and providing assurance of safety is an appropriate first step in managing severe anxiety. Once the client is more settled, other interventions can be explored.

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Correct Answer is D

Explanation

A. While sore throat and fever can be potential side effects of clozapine, informing UAP is not a proactive intervention. Regular monitoring of white blood cell (WBC) counts is crucial for
detecting clozapine-induced agranulocytosis.
B. Protective isolation is not a standard practice for clients taking clozapine. Monitoring for specific side effects, such as agranulocytosis, is more important.
C. Offering clozapine with food is not a priority intervention for managing potential side effects.
Monitoring and reporting WBC counts take precedence.
D. Clozapine is associated with the risk of agranulocytosis. Regular monitoring of WBC counts is essential, and any findings outside the normal range should be promptly reported to the
healthcare provider.

A. Ask the client to describe the history of the injuries. B. Invite a colleague to document during the interview. C. Close the examination room door for privacy. D. Request hospital security to come to the department.

Correct Answer is C

Explanation

A. While obtaining the client's history is important, ensuring privacy is a priority to maintain confidentiality and facilitate open communication.
B. Inviting a colleague to document is not the immediate priority; privacy is crucial in the initial stages of the interview.
C. Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history.
D. Requesting hospital security is not necessary at this point, as the spouse pacing outside does not necessarily indicate a security threat.

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A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client’s plan of care?

Correct Answer is D

Explanation

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

Correct Answer is C

Explanation

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

An adolescent who is exhibiting a depressed affect receives a prescription for an antidepressant drug. While the client is taking the antidepressant, which comparison of the client’s behavior before and after taking the drug is most important for the nurse to obtain?

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

During a high school substance abuse class, a student tells the group, “I know that marijuana is not addicting, so why shouldn’t I use it? Which response is best for the nurse to provide?