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.

Answer and Explanation

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.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale: Disrupted sleep is a common symptom of postpartum depression, and clients may experience difficulty falling asleep or staying asleep.

Choice B rationale: Grandiosity is more indicative of bipolar disorder (mania) rather than postpartum depression.

Choice C rationale: Poor concentration is a common cognitive symptom associated with postpartum depression.

Choice D rationale: Compulsive behavior is not typically associated with postpartum depression.

Choice E rationale: Sadness is a hallmark symptom of depression, including postpartum depression.

A. The nurse is stating disapproval of the statement. B. Silence is reflecting the client's sadness. C. Silence allows the client to reflect on what was said. D. The nurse is respecting the client's loss.

Correct Answer is C

Explanation

Choice A rationale: Remaining silent does not necessarily indicate disapproval; it is a therapeutic communication technique to allow the client to express feelings without interruption.

Choice B rationale: While the client may be experiencing sadness, the nurse's silence is not reflecting the client's emotions but rather providing space for the client to express their thoughts and feelings.

Choice C rationale: Silence, in this context, is therapeutic because it allows the client time and space to reflect on and explore their own thoughts and feelings. It promotes self-discovery and expression.

Choice D rationale: Respecting the client's loss is a general principle, but the specific therapeutic use of silence in this situation is to allow the client to process and express their emotions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior?

Correct Answer is C

Explanation

A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A client with obsessive compulsive disorder (OCD) reports feeling "driven" to check the locks on the front door at least six times every night. Which response is best for the nurse to provide?

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A client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because of a stalker. Which action is most important for the nurse to take?

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?