A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Encourage verbalization of feelings.

Provide an activity for diversion.

Remain with the client.

Have the client identify two coping skills.

Answer and Explanation

The Correct Answer is C

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

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Correct Answer is B

Explanation

Whether the client is a danger to herself or others. When a client is involuntarily admitted to a mental health unit, they are held for an initial period of 72 hours for evaluation and treatment. Afterward, a determination must be made as to whether or not the client is still a danger to themselves or others to keep them in the hospital.

Choices A, C, and D do not address the primary concern of ongoing safety for the client and others.

For choice A, the client's financial status or their ability to pay for prescribed medications is not relevant to their safety or need for hospitalization.

For choice C, the client's ability to make arrangements to stay with someone is important for discharge planning but not for determining their need for ongoing hospitalization.

Finally, for choice D, whether the client is unwilling to accept treatment is important, but not the sole determining factor as to whether they are a danger to themselves or others.

A. "I was monitoring my blood glucose every 3 to 4 hours." B. "I had to stop my insulin." C. "I called the doctor because of these symptoms." D. None of the above.

Correct Answer is B

Explanation

When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.

Therefore, these are not indications for further teaching.

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A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

Correct Answer is B

Explanation

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

Correct Answer is B

Explanation

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