A nurse is completing an admission assessment for a client who has obsessive- compulsive disorder and is becoming increasingly anxious. Which of the following actions should the nurse take first?
Teach the client about manifestations of anxiety.
Complete the client's assessment.
Provide reassurance of safety to the client.
Administer an anti-anxiety medication to the client.
The Correct Answer is C
Choice A rationale:
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
Choice B rationale:
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
Choice C rationale:
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
Choice D rationale:
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
People with dementia may become disoriented and attempt to leave their homes. Disguising exit doors with posters or camouflage can help prevent wandering and promote safety.
Choice B rationale:
Weighing the client once per month is not directly related to dementia care and safety.
Choice C rationale:
Keeping lights on at night can help prevent falls and confusion in people with dementia.
Choice D rationale:
Offering several food choices prior to meal times can be overwhelming for a person with dementia. A simpler approach may be more appropriate.
Correct Answer is A
Explanation
Choice A rationale:
Keeping the television on at a low volume in the background can provide sensory stimulation and a familiar environment for the client with Alzheimer's disease. It can also help decrease feelings of isolation and confusion.
Choice B rationale:
Abstract paintings may be confusing or agitating for a person with Alzheimer's disease. Familiar and recognizable decorations are more suitable.
Choice C rationale:
Reorienting the client daily to the day and time can be helpful, but it is not the priority teaching in this context.
Choice D rationale:
Using dim lighting is not recommended as it can contribute to confusion and disorientation in a person with Alzheimer's disease. Adequate lighting is important for safety and orientation.
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