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 C
Explanation
Choice A rationale: "If your partner is abusing you, I need to ask these questions" may be too direct and could potentially make the client feel pressured or uncomfortable. The nurse should emphasize the routine nature of the screening.
Choice B rationale: "The healthcare provider needs to know if you are experiencing any domestic abuse" is correct but may sound directive. Emphasizing the routine nature of the screening helps to normalize the process.
Choice C rationale: "All clients are screened for domestic abuse because it is common in our society" is the best choice. It normalizes the screening process, reducing stigma and encouraging disclosure.
Choice D rationale: "State law mandates that I ask if you are a victim of domestic violence" may make the client feel compelled to answer due to legal reasons, potentially affecting the validity of the response. Emphasizing routine screening is a more patient centered approach.
Correct Answer is D
Explanation
Choice A rationale: Screening the client for domestic violence requires a more comprehensive assessment and interpretation of findings, which is beyond the scope of practice for the UAP.
Choice B rationale: Determining the client's risk for suicide involves complex judgment and should be assessed by a licensed healthcare provider, not a UAP.
Choice C rationale: Asking the client to state a chief complaint for admission involves initial communication and assessment skills, which should be performed by licensed nursing staff.
Choice D rationale: Obtaining a baseline set of vital signs is a routine task that can be delegated to the UAP. It is a non-complex and standard part of the admission process.
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