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 A
Explanation
Choice A reason: The 'thinking/content of thought' section of the Mental Health Status Examination assesses the logical process of thought, presence of delusions, obsessions, and preoccupations.
Choice B reason: 'Memory' assesses the person's ability to recall past events, which is not directly related to their current thought content.
Choice C reason: 'Judgment' evaluates the ability to make reasoned decisions, which, while important, is distinct from the content of thought.
Choice D reason: 'Speech and the ability to communicate' assesses the clarity, relevance, and coherence of speech, not the internal thought process.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Mood and affect are essential components of the mental health status examination, reflecting the patient's emotional state and its expression.
Choice B reason: Memory is a cognitive function that is assessed during the mental health status examination to determine if there are any deficits.
Choice C reason: Judgment is evaluated to understand the patient's decision-making abilities, which can be affected in various mental health conditions.
Choice D reason: "Mood and tone" is not a standard component of the mental health status examination. The term "tone" typically refers to the quality of voice or speech.
Choice E reason: Level of awareness and orientation are assessed to determine the patient's consciousness level and their awareness of time, place, and person.
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