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.

Answer and Explanation

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.

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Correct Answer is ["A","B","C","E"]

Explanation

When caring for an adolescent female with an eating disorder, the nurse should expect the following manifestations:

A- Amenorrhea: Amenorrhea refers to the absence of menstruation, which is commonly seen in individuals with eating disorders, particularly in cases of severe weight loss or malnutrition.

B- Altered body image: Individuals with eating disorders often have a distorted perception of their body shape and size. They may see themselves as overweight or have a negative body image, even when they are significantly underweight.

C- Hyperactivity: Some individuals with eating disorders may exhibit excessive physical activity or restlessness. This hyperactivity can be a result of increased energy expenditure, driven by a fear of weight gain or a compulsive need to burn calories.

E- Bradycardia: Bradycardia, or a slow heart rate, is a common finding in individuals with severe malnutrition or very low body weight. It can be a result of the body's adaptive response to conserve energy in a state of limited food intake.

Incorrect:

D- Verbalized desire to gain weight is not typically expected in individuals with eating disorders. They may express a desire to lose weight or have a fear of gaining weight instead.

A. "Most clients with anxiety issues benefit from lying down." B. "An antianxiety pill works best for situations like this." C. "Providers usually recommend relaxation exercises for clients who are as upset as you are." D. "Come with me to an area where we can talk without interruption."

Correct Answer is D

Explanation

This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.

A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.

B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.

C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.

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A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?