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 B
Explanation
Choice A rationale:
While wearing a supportive bra is generally advisable, wearing it 24 hours a day is not necessary and may cause discomfort.
Choice B rationale:
Performing a breast self-exam 1 week after menstruation is recommended for individuals with fibrocystic breast condition. Hormonal changes during the menstrual cycle can affect breast tissue, and examining the breasts when they are less likely to be affected by hormonal fluctuations can provide a more accurate baseline for self-examination.
Choice C rationale:
Mammograms are recommended more frequently than every 4 years, especially for those with fibrocystic breast condition or other risk factors.
Choice D rationale:
Increasing caffeine intake can exacerbate symptoms of fibrocystic breast condition. Caffeine is known to contribute to breast pain and tenderness.
Correct Answer is A
Explanation
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
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