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. Clients taking disulfiram must completely avoid alcohol, as even small amounts can cause severe reactions (e.g., nausea, vomiting, flushing, hypotension). There is no safe amount of alcohol to consume while on this medication.
B. Alcohol consumption must be completely avoided, not just limited, while taking disulfiram, as the drug works by causing an aversive reaction when alcohol is ingested.
C. Disulfiram should not be started immediately if alcohol is still in the system. It must be initiated at least 12–48 hours after the last drink to prevent severe reactions.
D. The client should begin taking disulfiram at least 48 hours after the last alcohol intake to reduce the risk of adverse effects. The medication is taken daily, and alcohol must be strictly avoided, including in hidden sources like mouthwash and cooking extracts.

A. Share personal values to put the client at ease. B. Ask questions in a vague, non-specific format. C. Begin with questions that are less sensitive in nature. D. Get the most difficult questions over with first.

Correct Answer is C

Explanation

A. Sharing personal values may blur professional boundaries and could potentially influence the client's responses, which is not appropriate in a therapeutic setting.
B. Asking questions in a vague, non-specific format may not yield accurate or detailed information about the client's suicidal ideations.
C. Beginning with less sensitive questions allows the client to gradually build trust and rapport with the nurse before addressing more sensitive topics like suicidal ideation.
D. Getting the most difficult questions over with first may overwhelm the client and hinder the development of trust and rapport, which are crucial for effective communication in addressing sensitive topics like suicidal ideation.

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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 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?

Correct Answer is D

Explanation

Which is the best approach for the nurse to use when interviewing a client about suicidal ideations?

Correct Answer is C

Explanation

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