nurse tara is admitting Ms. Simpson. which of the following is the priority action for tara to take?
Assess respiratory status

the priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to the client is to assess respiratory status of a client who is experiencing shortness of breath and tachypnea

nurse tara is assessing Ms. Simpson. which of the following assessment scales is an appropriate tool for tara to use?

the nurse should use the Hamilton-A assessment scale to assess anxiety. the client has shortness of breath, chest pain, headaches, restlessness, and trembling

nurse tara completes the Hamilton-A assessment of ms. Simpson and determines her score to be 26. which of the following is an appropriate action for the nurse to take?
obtain a prescription for lorazepam (Ativan)

a score of 26 on the Hamilton-A assessment indicates a severe level of anxiety. therefore, obtaining a prescription for lorazepam (Ativan) is appropriate. clients who have a severe level of anxiety should receive a short-acting benzodiazepine, such as lorazepam, as an anxiolytic agent

nurse tara is preparing to call the provider. list the findings that the nurse includes when giving report using the SBAR format
S (Situation) = Ms. Simpson is a 22-year-old African-American female admitted to the inpatient mental health unit for anxiety. She is restless and fidgety, has poor concentration, and has been experiencing chest pain and shortness of breath.
B (Background) = She has a history of generalized anxiety disorder and has previously taken paroxetine 20 mg PO daily, but has not been taking it for approximately 2 weeks.
A (Assessment)= Her vital signs from report at 0745 were: heart rate 115, blood pressure 148/76, respirations 32, oxygen saturation 96% on room air, and temperature 37.0 C (98.6 F). Her score on the Hamilton A scale is 26, and she has been unable to focus on answering questions due to her severe level of anxiety. She continues to pace, wring her hands, and rock when sitting.
R (Recommendation) = I am calling to request a prescription for lorazepam.
nurse tara is calculating the dose of lorazepam (Ativan). available is lorazepam 4 mg/mL. how many mL should the nurse administer? prescribed dose is 2mg
0.5 mL

4 mg/1 mL = 2 mg/XmL
if there are 4 mg/mL and the amount prescribed is 2 mg, it makes sense to administer 0.5 mL. the nurse should administer lorazepam 0.5 mL IM.

nurse tara is initiating therapeutic communication with ms. Simpson. which of the following video clips demonstrates an appropriate interaction between the nurse and the client?
video c

engaged and active listening, including direct eye contact, are key principles of effective communication and will assist in building a rapport with the client

nurse tara is communicating with ms. simpson. which of the following is an appropriate action for tara to take
restate the concerns voiced by ms. simpson

restating the client’s concerns allows for exploration and clarification of the client’s statements

nurse tara is listening to ms. simpson while she describes the stressors that contribute to her anxiety. which of the following coping mechanisms is ms. simpson exhibiting? select all that apply
– denial
– displacement
– rationalizing

denial: conscious effort to not thinking about an unpleasant event or occurrence that is causing stress
displacement: happens when there is a transfer of feelings about an individual or circumstance to another person or object that is uninvolved in the situation
rationalization: belief in or acting upon an idea that is unrealistic in order to satisfy the response of the communicator and the listener

the client knowing that her boyfriend will return is denial; the client blaming the boyfriend’s drinking and gambling behavior to be the cause of her inability to pay rent is displacement; the client stating that she will be fine without assistance is rationalization

nurse tara is discussing ms. simposon’s most stressful situation. which of the following actions should tara take first?
continue to gather more information regarding finances

the first action the nurse should take using the nursing process is to collect data from the client

nurse tara has discovered ms. simpson’s self-injury. which of the following thought processes is most likely a reflection of ms. simpson’s behavior?
alleviation of psychological pain

self-injury in this client is a mode of alleviating psychological pain by causing physical pain

nurse tara is providing medication teaching regarding escitalopram (lexapro). which of the following statements should tara include in the teaching?
“you should report increased thoughts of suicide.”

clients, especially children and young adults, who start therapy with escitalopram are at increased risk for suicide ideation. the nurse should report changes in behavior to the provider

nurse tara is explaining ms. simpson’s diagnosis. which of the following statements should tara include in the teaching? select all that apply
– “interventions are based on the degree of anxiety you are experiencing.”

– “you can experience four levels of anxiety.”

– “it is common to perform repetitive behaviors in order to cope with anxiety.”

treatment of anxiety is individualized to degree of anxiety the client is experiencing. the four levels of anxiety include mild, moderate, severe, and panic. manic and depressive episodes are key features in bipolar disorder. it is common to perform repetitive behaviors in order to cope with anxiety, such as continual hand washing. grandiose thoughts are common in clients experiencing delusions, and also occur in a manic phase of bipolar disorder.

nurse tara is teaching ms. simpson about anxiety. which of the following indicate ms. simpson understands the teaching?
uses relaxation techniques

using relaxation techniques is an indicator of positive self-control. additional indicators include monitoring of anxiety levels and environmental distractions and the ability to maintain restful sleep

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