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.

Answer and Explanation

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.

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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.

A. Eliminate unhealthy food from the diet. B. Avoid eating foods containing dairy. C. Drink 240 mL (8 oz) of water with each meal. D. Eat foods at colder temperatures. E. Eat foods at colder temperatures.

Correct Answer is D

Explanation

Choice A rationale:

Eliminating unhealthy foods is generally a good practice, but specific guidance related to managing hyperemesis gravidarum is needed.

Choice B rationale:

Dairy products can be included in the diet unless the client has a specific intolerance or allergy.

Choice C rationale:

Drinking water with each meal can be helpful, but avoiding dehydration is more important. Fluid intake should be consistent throughout the day.

Choice D rationale:

Hyperemesis gravidarum is a condition that causes severe nausea and vomiting during pregnancy, which can lead to dehydration, electrolyte imbalance, and weight loss. To prevent or reduce these complications, the nurse should instruct the client to eat foods at colder temperatures, as they are less likely to trigger nausea than hot or spicy foods. The client should also eat small, frequent meals and avoid foods that are greasy, fatty, or have strong odors.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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