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 A

Explanation

A. Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness.
B. Cocaine use is associated with tachycardia (increased heart rate) rather than bradycardia, and it usually increases respiratory rate rather than causing bradypnea.
C. Hallucinations and delusions are not typical effects of cocaine use; instead, they may occur with substances like hallucinogens or certain psychotic disorders.
D. Lethargy and depression are more commonly associated with the "crash" or comedown phase after cocaine use, rather than immediate effects of ingestion.

A. Reinforce the need for the adolescent to attend group therapy sessions. B. Tell the mother to describe her feelings of helplessness to her child. C. Advise the mother to call the police if violent behavior occurs again. D. Refer the mother for psychiatric evaluation for anxiety and depression.

Correct Answer is C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

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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

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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