A client who is experiencing a severe level of anxiety and reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
Speak calmly to the client stating assurance of safety.
Attempt to distract to another focus or activity.
Help the client to identify thoughts that may be triggers.
Explore past behaviors that have provided relief.
The Correct Answer is A
Choice A rationale: Speaking calmly and assuring the client of safety is a therapeutic intervention for managing severe anxiety and panic. It helps provide a sense of reassurance and safety to the client during an acute anxious episode.
Choice B rationale: Attempting to distract the client can be helpful in some situations, but in severe anxiety, the focus should initially be on providing a sense of safety and addressing immediate distress.
Choice C rationale: Helping the client identify thoughts is more appropriate during less acute moments or in the context of cognitive-behavioral therapy. In severe anxiety, the immediate focus is on providing support and reassurance.
Choice D rationale: Exploring past behaviors may be part of a comprehensive assessment but is not the first priority during an acute episode of severe anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Asking the client what they think should happen is vague and does not offer any direction or support.
Choice B rationale: This response encourages is vague and does not offer any direction or support but instead puts the burden of decision-making on the client who is overwhelmed and distressed.
Choice C rationale: Inquiring about the seriousness of the collision is important but may not be the most immediate concern when the client is seeking guidance on what to do.
Choice D rationale: This response shows empathy and concern for the client's well-being and helps the client take action to cope with the crisis.
Correct Answer is C
Explanation
Choice A rationale: Telling the client that irrational thinking is a symptom of schizophrenia may not be well-received and could lead to increased resistance. It is essential to address the immediate concern of food refusal.
Choice B rationale: Assuring the client that all food served in the hospital is safe to eat may not be sufficient, especially if the client has strong delusional beliefs about poisoning. Offering food in unopened containers is a more practical approach. Choice C rationale: Providing the client with food in unopened containers is a reasonable intervention. It addresses the client's concerns about poisoning and ensures that the food is perceived as safe.
Choice D rationale: Obtaining an order for a tube feeding for the client may be considered if the client continues to refuse solid food. However, providing food in unopened containers is an initial step to encourage the client to eat.
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