During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?
Remain calm and use a matter-of-fact approach.
B Assist the client in developing alternative coping skills.
Administer an as needed (PRN) sedative to help relieve anxiety.
Ask the client why she is so anxious.
The Correct Answer is A
Choice A rationale: Remaining calm and using a matter-of-fact approach helps provide a sense of security and reduces anxiety in the client during admission.
Choice B rationale: Assisting the client in developing alternative coping skills is important but may not be the first action during the initial admission process.
Choice C rationale: Administering a sedative may be considered if the client's anxiety is severe, but understanding and addressing the underlying cause of anxiety is the priority.
Choice D rationale: Asking the client why she is anxious may be appropriate, but the initial focus is on providing a calming and supportive environment during admission.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Thiamine (vitamin B1) is the appropriate medication for Wernicke Korsakoff syndrome, as it addresses thiamine deficiency associated with chronic alcohol use, which can contribute to neurological symptoms.
Choice B rationale: Chlordiazepoxide is a benzodiazepine used for alcohol withdrawal symptoms but does not address the underlying thiamine deficiency in Wernicke Korsakoff syndrome.
Choice C rationale: Clonidine is not indicated for the treatment of Wernicke-Korsakoff syndrome; it is primarily used for managing withdrawal symptoms in opioid or alcohol dependence.
Choice D rationale: Carbamazepine is not the appropriate medication for Wernicke Korsakoff syndrome; it is commonly used for mood stabilization in conditions like bipolar disorder.
Correct Answer is C
Explanation
Choice A rationale: Reports difficulties with short-term memory since a traumatic brain injury is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specifically designed to screen for alcohol use disorder.
Choice B rationale: Medical history, including recent sexual assault, does not directly correlate with the need for the CAGE questionnaire. The CAGE questionnaire focuses on identifying problematic alcohol use.
Choice C rationale: Describing self as a social drinker who drinks alcoholic beverages daily is an indication for using the CAGE questionnaire. The client's daily consumption and identification as a social drinker raise concerns about potential alcohol misuse or dependency.
Choice D rationale: Client's medication history, including the frequent use of antidepressants, is not an indication for using the CAGE questionnaire. The CAGE questionnaire is specific to alcohol use and does not address antidepressant use.
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