A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Establish trust by providing a calm, safe environment.

Encourage deep breathing when anxiety escalates in a crowd.

Progressively expose the client to larger crowds.

Encourage substitution of positive thoughts for negative ones.

Answer and Explanation

The Correct Answer is A

A.   Establishing trust by providing a calm, safe environment is crucial for clients with agoraphobia, as it lays the foundation for effective therapeutic interventions and supports the client's sense of safety and security.
B.   Encouraging deep breathing is a helpful coping strategy, but it may not be the highest priority compared to establishing trust and safety.
C.   Progressively exposing the client to larger crowds is part of desensitization therapy, but it should be done gradually and only after trust and rapport have been established.
D.   Encouraging substitution of positive thoughts for negative ones is a valuable cognitivebehavioral technique, but it may be more effective once the client feels safe and supported in the therapeutic environment.

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Correct Answer is C

Explanation

A. Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B. Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C. Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D. Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

A. I hear you say you worry about causing your mother's distress. B. Are you afraid that your mother's depression will lead to her death? C. What do you think you did that led to your mother's depression? D. You are not alone in feeling responsible for others in your family. E. You are not alone in feeling responsible for others in your family.

Correct Answer is A

Explanation

A. This response acknowledges the daughter's feelings without making assumptions or placing blame, fostering open communication and understanding within the family group.
B. This response may escalate the daughter's anxiety and is not directly related to her statement about causing her mother's depression.
C. This response may inadvertently encourage the daughter to blame herself for her mother's depression, which is not helpful in addressing family dynamics.
D. This response may put the daughter on the spot and could make her feel defensive or misunderstood, hindering effective communication within the family group.

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A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause Mom to be depressed." Which response is best for the nurse to provide?

Correct Answer is A

Explanation

A client who is an alcoholic receives a prescription for disulfiram 500 mg by mouth (PO) daily. Which instruction should the nurse provide to this client?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A client with schizophrenia returns to the clinic two weeks after receiving a prescription for haloperidol. To assess for neuroleptic malignant syndrome (NMS), which information is most important for the nurse to obtain during this visit?

The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?