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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response is empathetic and reassuring, affirming the nurse's role in providing care and support, which is essential in managing patients with schizophrenia who may experience feelings of paranoia or imprisonment.
Choice B reason: Asking if the patient feels they don't belong could reinforce feelings of alienation or paranoia. It's important to provide reassurance rather than question their sense of belonging.
Choice C reason: While deep breathing can be a calming technique, assuring the patient they will feel better may not address their immediate concerns or the reality of their feelings.
Choice D reason: Asking why they feel the need to leave could challenge the patient's experience and potentially escalate their distress. It's important to validate their feelings and provide reassurance.
Correct Answer is A
Explanation
Choice A reason: Serving food in sealed packaging can help alleviate the client's fears of poisoning, as the intact seals provide visual assurance that the food has not been tampered with.
Choice B reason: While serving warm foods with lids may keep the food warm, it does not necessarily provide the same level of reassurance against the fear of poisoning as sealed packaging does.
Choice C reason: Serving the same food as others may not be effective if the client's delusions include beliefs that they are being specifically targeted.
Choice D reason: Although serving the client's favorite foods in an attractive arrangement may be appealing, it does not address the specific paranoid delusion of food being poisoned.
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