A patient is being treated on the mental health unit for an anxiety disorder. The patient approaches the nurse and reports feeling dizzy and weak, with a sensation of a racing heart. The nursing care plan includes interventions of imagery exercises and as-needed lorazepam (Ativan) for symptoms of anxiety. What should the nurse do first?

Obtain the patient's vital signs.

Give the patient the prescribed as-needed lorazepam.

Instruct the patient to sit and breathe deeply.

Instruct the patient in an imagery exercise.

Answer and Explanation

The Correct Answer is A

Choice A reason: The first step should always be to assess the patient's physical state to rule out any immediate life-threatening conditions before proceeding with psychiatric interventions.

Choice B reason: Administering medication may be necessary, but it should not precede an assessment of the patient's vital signs.

Choice C reason: While instructing the patient to sit and breathe deeply can help alleviate symptoms of anxiety, it is not the first action to take before assessing the patient's vital signs.

Choice D reason: Imagery exercises can be helpful for managing anxiety, but they are not the priority before ensuring the patient's physiological stability.

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Correct Answer is C

Explanation

Choice A reason: Conversion typically refers to the expression of psychological distress through physical symptoms, which is not the case here.

Choice B reason: Undoing is a defense mechanism where a person tries to 'undo' an unhealthy thought or behavior with a healthier one, which does not apply to Michael's situation.

Choice C reason: Compensation is a defense mechanism where a person overachieves in one area to make up for deficiencies in another, which describes Michael's actions.

Choice D reason: Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not explicitly indicated in this scenario.

A. Clang association B. Neologism C. Echolalia D. Word salad

Correct Answer is B

Explanation

Choice A reason: Clang association involves speech governed by words that sound alike rather than having a logical connection, which is not demonstrated here.

Choice B reason: Neologism is the creation of new words or phrases that others may not understand, which fits the use of "muxtranks."

Choice C reason: Echolalia is the repetition of another person's spoken words, which is not the case here.

Choice D reason: Word salad refers to a jumble of words that is incoherent, but "muxtranks" is a consistent term used by the client, indicating neologism.

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Naxlex Comprehensive Predictor Exams

Michael's parents have always told him that he is not a good student. Michael starts a small business selling things on the internet and devotes all his time and energy to building it, becoming a successful entrepreneur. Michael's situation is an example of:

Correct Answer is C

Explanation

A nurse overhears a client who has schizophrenia talking to herself. The client keeps stating, "The muxtranks are coming. The muxtranks are coming." The nurse correctly recognizes the client's use of the word "muxtranks" as an example of which of the following alterations in speech?

Correct Answer is B

Explanation

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