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 D
Explanation
Choice A reason: This describes tactile hallucinations, a false sensory experience, not a delusion of reference.
Choice B reason: This reflects a persecutory delusion, where the client believes they are being harmed or targeted, not a delusion of reference.
Choice C reason: This illustrates an auditory hallucination with command-type voices, not a delusion of reference.
Choice D reason: Believing that unrelated environmental cues (like a song) carry special, hidden meaning specifically for the client is the hallmark of a delusion of reference.
Correct Answer is B
Explanation
Choice A reason: Forcibly removing the client escalates anxiety and can increase resistance. This action does not support therapeutic management of OCD.
Choice B reason: Providing a clear, respectful, and time-limited reminder supports structure and helps the client redirect behavior without confrontation. It balances therapeutic boundaries with empathy.
Choice C reason: Dismissing the client’s concern as unreasonable invalidates their experience, increasing defensiveness and mistrust. This does not support treatment goals.
Choice D reason: Avoiding the problem by redirecting the roommate fails to address the client’s compulsive behavior and disrupts the care environment.
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