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 C
Explanation
Choice A rationale:
Newborns typically lose some weight after birth, but 15 percent loss would be excessive and concerning. A normal weight loss range is about 5 to 10 percent.
Choice B rationale:
Newborns should be fed on demand rather than adhering to strict schedules to ensure they are adequately nourished.
Choice C rationale:
Breastfeeding requires additional energy, and mothers are generally advised to consume around 500 extra calories a day to support milk production and their own energy needs.
Choice D rationale:
Offering a pacifier before sleep can reduce the risk of sudden infant death syndrome (SIDS), but this recommendation usually starts at around 1 to 2 months of age.
Correct Answer is C
Explanation
Choice A rationale:
A hemoglobin level of 13 g/dL is within the normal range and is not specifically indicative of HELLP syndrome.
Choice B rationale:
A blood urea nitrogen (BUN) level of 8 mg/dL is within the normal range and is not typically associated with HELLP syndrome.
Choice C rationale:
Elevated bilirubin levels are a characteristic feature of HELLP syndrome, which involves liver dysfunction.
Choice D rationale:
A hematocrit level of 38% is within the normal range and is not specifically indicative of HELLP syndrome.
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