A client in the psychiatric unit is experiencing severe anxiety—they are trembling, pacing, and saying, "I can’t think straight. I feel like something terrible is going to happen." Which of the following is the most therapeutic response by the nurse?
"You need to stop thinking this way. Nothing bad is going to happen."
"Let’s sit together here quietly. I’ll stay with you until you feel more in control."
"Try to calm down. You're safe here, so there’s nothing to worry about."
"Why are you so anxious? Can you tell me what triggered this feeling?"
The Correct Answer is B
Choice A reason: Telling the patient to stop thinking a certain way invalidates their feelings and is not therapeutic.
Choice B reason: Offering presence and calm support provides safety and helps reduce anxiety. It is the most therapeutic intervention for severe anxiety.
Choice C reason: Telling the patient not to worry may feel dismissive, and in severe anxiety the patient may not be able to process reassurance.
Choice D reason: Asking "why" is not effective when the patient is overwhelmed by severe anxiety, as they cannot engage in rational discussion at that moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the patient’s feelings without confirming or denying the delusion. It helps establish trust while maintaining therapeutic communication. By focusing on the patient’s underlying concern, it avoids reinforcing the delusional content.
Choice B reason: Stating that the CIA is prohibited in health care facilities engages with the delusion, which is non-therapeutic because it validates the false belief.
Choice C reason: Redirecting away from the delusion may seem dismissive and does not address the patient’s immediate feelings of fear or concern. This could cause the patient to feel unheard.
Choice D reason: Telling the patient they have “lost touch with reality” is confrontational and could increase defensiveness. It is not supportive or therapeutic in building rapport.
Correct Answer is C
Explanation
Choice A reason: When anxiety is severe, the client cannot focus or process complex discussions. Asking them to explore worries may overwhelm them further.
Choice B reason: Providing extensive information is inappropriate in crisis moments because the client’s concentration and comprehension are impaired.
Choice C reason: Clear, calm, and brief communication helps reduce overstimulation, provides structure, and reassures the client during high anxiety. This is the most therapeutic choice.
Choice D reason: Rapid statements can escalate the client’s sense of being overwhelmed, increasing anxiety rather than calming it.
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