A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Administer an anti-anxiety medication.

Explore behaviors that have helped to reduce the client's anxiety in the past.

Minimize environmental stimuli in the client's surroundings.

Explain to the client that anxiety causes physical manifestations

Answer and Explanation

The Correct Answer is C

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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Correct Answer is D

Explanation

Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.

Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.

Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.

Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.

A. "I will place my newborn face up on a pillow when sleeping." B. "I will make sure that I can fit one finger between the mattress and the side of my newborn's crib." C. "I will attach the pacifier to my newborn's clothing with a string at bedtime:" D. "I will place my newborn's crib near a heat vent during cold weather"

Correct Answer is B

Explanation

The guideline of being able to fit one finger between the mattress and the side of the crib ensures that there is a safe space to prevent entrapment and suffocation risks.

Placing a newborn on a pillow for sleep is unsafe. Infants should be placed on their backs to sleep on a firm, flat surface without pillows, blankets, or soft bedding. This reduces the risk of suffocation or sudden infant death syndrome (SIDS).

Attaching a pacifier to the newborn's clothing with a string is hazardous. Strings and cords pose a strangulation risk. Pacifiers should be used according to safe guidelines, but they should not be attached to the baby's clothing with any type of string or cord.

Placing a newborn's crib near a heat vent can result in overheating, which is a safety concern. It is important to keep the baby's sleep environment at a comfortable temperature without direct exposure to heat sources or drafts

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A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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