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 A

Explanation

A) Rotating the earmold forward when inserting the hearing aid is a correct technique. This ensures a proper fit and helps to position the hearing aid comfortably in the ear canal, which can enhance the effectiveness and comfort of the device.

B) Cleaning the hearing aid with alcohol swabs can damage the delicate components of the device. Instead, hearing aids should be cleaned with a dry cloth or a soft brush specifically designed for this purpose to avoid damaging the hearing aid.

C) Turning the hearing aid on before inserting it may result in feedback or a whistling sound. It's usually recommended to insert the hearing aid first and then turn it on to avoid any discomfort or unwanted noise.

D) If the hearing aid whistles, it is not typically related to the battery. Whistling is often caused by improper fit, earwax buildup, or feedback issues. Changing the battery is unlikely to resolve the whistling problem and is not the recommended solution.

A. Staying current on scheduled immunizations B. Maternal smoking during pregnancy C. Newborn who is large for gestational age D. Meconium staining of amniotic fluid

Correct Answer is B

Explanation

A) Staying current on scheduled immunizations: Staying up-to-date with immunizations is important for overall child health but is not a direct risk factor for sudden infant death syndrome (SIDS). Immunizations can help prevent infections that could contribute to SIDS but are not directly related to the syndrome itself.

B) Maternal smoking during pregnancy: Maternal smoking during pregnancy is a well-documented risk factor for SIDS. Exposure to nicotine and other harmful substances from smoking can affect the baby's respiratory system and increase the likelihood of SIDS.

C) Newborn who is large for gestational age: Being large for gestational age is not a recognized risk factor for SIDS. SIDS risk factors are more closely associated with prenatal and postnatal conditions, rather than birth weight alone.

D) Meconium staining of amniotic fluid: Meconium staining of amniotic fluid is a condition that can indicate fetal distress during labor but is not a direct risk factor for SIDS. It is more related to potential complications during delivery rather than SIDS risk.

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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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Correct Answer is B

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