An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam. During the health assessment, the client reports experiencing of chest pain. Which action should the nurse take first?
Refer the client to the cardiology clinic.
Obtain the client's blood pressure.
Determine if alprazolam was taken recently.
Assess the client for substance abuse.
The Correct Answer is B
Choice A rationale: Referring the client to the cardiology clinic may be necessary, but obtaining the client's blood pressure is the priority to assess the immediate need for intervention and determine the appropriate course of action.
Choice B rationale: Obtaining the client's blood pressure is the most immediate and relevant action. Chest pain is a potentially serious symptom, and assessing blood pressure will help determine the urgency of the situation.
Choice C rationale: Determining if alprazolam was taken recently is important but may not be the immediate priority when the client is reporting chest pain. Assessing vital signs is crucial in this situation.
Choice D rationale: Assessing the client for substance abuse is relevant to the overall care of the client but may not be the immediate priority when chest pain is reported. The nurse should address potential medical emergencies first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Encouraging an increase in oral fluids is a general intervention but may not address the specific concern related to a sore throat and elevated temperature.
Clozapine requires monitoring for potential agranulocytosis, and an infection should be ruled out with a complete blood count (CBC).
Choice B rationale: Obtaining a specimen for a complete blood count (CBC) is crucial to assess for clozapine-induced agranulocytosis, a potentially life-threatening side effect. A sore throat and fever are red flags for possible infection.
Choice C rationale: Completing an Abnormal Involuntary Movement Scale (AIMS) is not relevant to the current situation. A sore throat and fever require immediate attention to rule out infection.
Choice D rationale: Administering a PRN dose of acetaminophen may help reduce fever, but the priority is to investigate the potential cause of the symptoms. Obtaining a CBC is essential.
Correct Answer is A
Explanation
Choice A rationale: Changes in thought patterns related to problem-solving demonstrate the effectiveness of cognitive-behavioral techniques. Shifting from hopelessness to active problem-solving reflects positive progress.
Choice B rationale: Describing how the family can resolve problems may involve other therapeutic modalities, but it is not specific to evaluating the effectiveness of cognitive behavioral techniques.
Choice C rationale: Relating insight into problematic relationships is a broad goal and may not specifically measure the impact of cognitive-behavioral techniques. Choice D rationale: Demonstrating a healthy relationship with the husband is an important goal but is not directly related to the evaluation of cognitive-behavioral techniques.
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