A nurse is caring for a client who is experiencing anxiety. When using clinical decision making, which of the following actions should the nurse take first?

Measure the client's manifestations using an anxiety rating scale.

Initiate a referral to a local support group.

Assist in finding alternative ways to cope.

Administer an antianxiety medication.

Answer and Explanation

The Correct Answer is A

A) Measure the client's manifestations using an anxiety rating scale: This action is essential as the first step because it allows the nurse to accurately assess the severity of the client's anxiety. Understanding the level of anxiety helps in planning appropriate interventions and monitoring the effectiveness of any treatment provided. Accurate assessment is foundational in clinical decision making.

B) Initiate a referral to a local support group: While beneficial, referring the client to a support group should follow an initial assessment. Support groups can offer long-term benefits, but immediate needs and severity must be evaluated first.

C) Assist in finding alternative ways to cope: Helping the client develop coping strategies is an important intervention. However, before suggesting specific coping mechanisms, the nurse needs to understand the current level of anxiety and how it affects the client. This ensures that the coping strategies are appropriately tailored.

D) Administer an antianxiety medication: Administering medication can be crucial in managing severe anxiety, but this step should come after a thorough assessment. The nurse needs to determine if medication is necessary and what dosage might be appropriate, based on the anxiety rating scale and other assessment findings.

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Correct Answer is B

Explanation

A) "Switch from breastfeeding to formula feeding when your baby is 2 months old": Breastfeeding is associated with a reduced risk of otitis media, as breast milk contains antibodies and other factors that help protect against infections. Switching to formula feeding may not reduce the incidence of otitis media and can potentially increase the risk.

B) "Avoid exposing your baby to secondhand smoke": Exposure to secondhand smoke is a significant risk factor for otitis media. Smoke irritates the respiratory tract and can lead to inflammation and fluid accumulation in the middle ear, increasing the likelihood of ear infections. Avoiding secondhand smoke can help reduce the incidence of otitis media.

C) "Ensure your baby receives the Hepatitis B vaccine": While the Hepatitis B vaccine is important for preventing Hepatitis B infection, it does not have a direct impact on the incidence of otitis media. The vaccine’s primary role is in preventing liver disease rather than ear infections.

D) "Place your baby in a supine position during feeding": Placing a baby in a supine position (lying on their back) during feeding does not reduce the risk of otitis media. In fact, feeding a baby while lying flat can increase the risk of ear infections as it may cause milk to flow into the middle ear. It is generally recommended to hold the baby in an upright or semi-upright position during feeding.

A. A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube B. A preschooler awaiting discharge instructions prior to leaving the hospital C. A toddler who has a respiratory rate of 54/min D. A school-age child who reports nausea following chemotherapy

Correct Answer is C

Explanation

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

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A nurse is caring for a client who is experiencing anxiety. When using clinical decision making, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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