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 C

Explanation

A) Hiccups: Hiccups are not a common adverse effect of lisinopril. While they can be bothersome, they are not typically associated with this medication. Monitoring for more significant side effects is crucial, but hiccups alone are not usually indicative of a serious reaction.

B) Anxiousness: Anxiousness or anxiety is not a typical side effect of lisinopril. While anxiety can occur due to various factors, it is not directly linked to the use of lisinopril. The focus should be on more specific adverse effects related to the medication.

C) Cough: A persistent, dry cough is a well-documented adverse effect of lisinopril. Angiotensin-converting enzyme (ACE) inhibitors like lisinopril can cause a cough due to the accumulation of bradykinin. This side effect is significant and often leads to discontinuation of the medication.

D) Rhinorrhea: Rhinorrhea, or a runny nose, is not a common adverse effect of lisinopril. Although it can occur with other conditions or medications, it is not specifically associated with ACE inhibitors. Monitoring for more characteristic side effects of lisinopril is important.

A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is A

Explanation

A) Respiratory acidosis: This condition is indicated by a low pH (7.32) and an elevated PaCO2 (48 mm Hg), while HCO3 remains normal (24 mEq/L). Respiratory acidosis occurs when there is an accumulation of carbon dioxide in the blood, usually due to hypoventilation or impaired gas exchange in the lungs.

B) Metabolic acidosis: Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. In this scenario, the HCO3 level is normal, ruling out metabolic acidosis.

C) Respiratory alkalosis: Respiratory alkalosis is indicated by a high pH and a decreased PaCO2. In this case, the pH is low, and the PaCO2 is elevated, which contradicts the characteristics of respiratory alkalosis.

D) Metabolic alkalosis: Metabolic alkalosis would show a high pH and an elevated HCO3 level. Since the pH is low and the HCO3 is normal, this condition does not fit the criteria for metabolic alkalosis.

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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

A nurse is caring for a client who has hypertension and is taking lisinopril. The nurse should monitor the client for which of the following findings as an adverse effect of lisinopril?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client who was an unrestrained passenger in a motor-vehicle crash. The ABG results are as follows: pH 7.32, HCO3 24 mEq/L, PaCO2 48 mm Hg. The nurse should identify the client is experiencing which of the following acid-base imbalances?

Correct Answer is A

Explanation

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