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. Determine the client’s reason for attempting suicide: While assessing suicidal intent is important, the immediate priority is ensuring the client's physiological stability. Suicidal ideation can be addressed once the client is medically stable.

B. Obtain the client’s serum hydrocodone/acetaminophen level: This may be ordered, but it is not the highest priority. Clinical observation is more urgent, especially because naloxone has a shorter half-life than many opioids, including hydrocodone.

C. Encourage the client to increase fluid intake: This is not a priority intervention in the immediate post-overdose period and does not address the risk of opioid rebound toxicity.

D. Observe the client for further narcotic effects: Naloxone has a short duration of action (typically 30–90 minutes), whereas hydrocodone has a longer half-life. Once naloxone wears off, respiratory depression and sedation can recur. Continuous monitoring is critical to ensure timely re-administration if opioid effects return.

A. Disrupts group activities. B. Wanders into client’s rooms. C. Talks with nonsensical words. D. Refuses antipsychotic medications.

Correct Answer is B

Explanation

A. Disrupting group activities may be a concerning behavior, but it may not necessarily warrant constant observation.
B. Wandering into client’s rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
C. Talking with nonsensical words is indicative of disorganized thought processes but may not directly necessitate constant observation for safety.
D. Refusing antipsychotic medications is a concerning behavior, but it alone may not be an immediate safety risk that requires constant observation.

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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

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

Correct Answer is D

Explanation

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is B

Explanation

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

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?

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

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?