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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bursting open of the wound is a description that could imply evisceration, but it is not as specific as choice D.
Choice B reason: Wound edges not approximating is a general description of a wound that is not healing properly, but does not specifically describe evisceration.
Choice C reason: Opening of the wound could refer to any situation where a wound has opened, not necessarily evisceration.
Choice D reason: Evisceration specifically refers to the viscera spilling out of the abdomen, usually through a surgical wound.
Correct Answer is B
Explanation
Choice A reason: Evaluation is the final step of the nursing process, where the nurse determines the effectiveness of the nursing care provided.
Choice B reason: Assessment is the correct part of the nursing process for the mental status examination, as it involves collecting data about the patient.
Choice C reason: Planning involves setting goals and choosing appropriate nursing actions based on the assessment data.
Choice D reason: Implementation is the step where the nurse carries out the planned interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.