A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?
Instruct the client to remember past coping mechanisms.
Provide a diverting activity.
Encourage verbalization of feelings.
Remain with the client.
The Correct Answer is D
By remaining with the client, the nurse provides a sense of support and security. This presence can help alleviate the client's anxiety and provide reassurance. It also ensures that the nurse is available to assess the client's condition, offer therapeutic communication, and intervene if the anxiety escalates or the client becomes overwhelmed.
While the other options are also beneficial interventions for managing anxiety, they are not the priority in this situation. Instructing the client to remember past coping mechanisms (Option A) can be helpful, but the immediate presence of the nurse is more important to provide immediate support.
Providing a diverting activity (Option B) can be beneficial to distract the client from their anxiety, but it does not address the underlying anxiety or provide direct support.
Encouraging verbalization of feelings (Option C) is important for therapeutic communication, but it may not be the initial priority when the client is experiencing acute anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.The client runs 4 miles outdoors every afternoon. This is correct. Intense physical activity, especially in hot weather, can lead to dehydration and sodium loss through sweat, both of which can increase the risk of lithium toxicity.
B.The client drinks 2 liters of liquids daily. Adequate fluid intake helps maintain a stable lithium level and is generally recommended to reduce the risk of toxicity.
C. The client eats 2 to 3 gm of sodium-containing foods daily. A consistent intake of sodium helps maintain stable lithium levels. Significant changes in sodium intake, rather than a stable intake, would be more concerning.D. The client eats foods high in tyramine. Tyramine-rich foods are a concern for clients taking MAO inhibitors, not lithium. Therefore, this is not relevant to lithium toxicity.
Correct Answer is D
Explanation
By remaining with the client, the nurse provides a sense of support and security. This presence can help alleviate the client's anxiety and provide reassurance. It also ensures that the nurse is available to assess the client's condition, offer therapeutic communication, and intervene if the anxiety escalates or the client becomes overwhelmed.
While the other options are also beneficial interventions for managing anxiety, they are not the priority in this situation. Instructing the client to remember past coping mechanisms (Option A) can be helpful, but the immediate presence of the nurse is more important to provide immediate support.
Providing a diverting activity (Option B) can be beneficial to distract the client from their anxiety, but it does not address the underlying anxiety or provide direct support.
Encouraging verbalization of feelings (Option C) is important for therapeutic communication, but it may not be the initial priority when the client is experiencing acute anxiety.
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