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 D

Explanation

A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

A. Involve client in daily exercise program. B. Ask the client to describe her depression. C. Spend time sitting in silence with client. D. Observe for signs of possible psychosis.

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.

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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

A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determine the client is homeless and is exhibiting suspiciousness. This client's plan of care should include what priority problem?

Correct Answer is D

Explanation

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

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