A nurse is attending to a client experiencing acute anxiety.
Which of the following actions should the nurse undertake? (Select all that apply.)
Establish rapport with the client.
Avoid making eye contact when addressing the client.
Speak to the client using a high-pitched voice.
Validate the client’s feelings and identify the cause of the anxiety.
Correct Answer : A,D
Choice A rationale:
Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:
Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.
Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.
Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.
Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.
Techniques for establishing rapport:
Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.
Empathy: Show understanding and compassion for the client's experiences and feelings.
Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.
Genuineness: Be authentic and honest in your interactions with the client.
Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.
Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.
Choice B rationale:
Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.
Choice C rationale:
Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.
Choice D rationale:
Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.
Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
The correct answer is choice A and D.
Choice A rationale:
Establishing rapport with the client is a fundamental nursing action to create a trusting relationship, which is especially important when a client is experiencing acute anxiety. A strong rapport can help the client feel more secure and supported, making it easier to manage their anxiety.
Choice B rationale:
Making eye contact is generally considered a non-threatening and effective way to communicate care and attention. Avoiding eye contact could make the client feel isolated or ignored. Therefore, this is not a recommended action when attending to a client with acute anxiety.
Choice C rationale:
Using a high-pitched voice can be perceived as alarming or stressful, which may exacerbate the client’s anxiety. It is important to use a calm, soothing tone when speaking to someone who is anxious.
Choice D rationale:
Validating the client’s feelings and identifying the cause of the anxiety are therapeutic techniques that acknowledge the client’s experience and can help in addressing the underlying issues contributing to the anxiety. This can be a crucial step in helping the client to cope with and overcome their anxiety.
Correct Answer is ["C","D"]
Explanation
Choice C rationale:
Sodium level is a critical electrolyte that plays a vital role in maintaining fluid balance, nerve and muscle function, and blood pressure. Naltrexone, one of the medications the patient is taking, has the potential to cause hyponatremia (low sodium levels) as a side effect. Hyponatremia can manifest with various symptoms, including headache, nausea, vomiting, confusion, seizures, and even coma in severe cases. Prompt recognition and management of hyponatremia are crucial to prevent serious complications.
Rationale for Immediate
Potential for Hyponatremia: Naltrexone, an opioid antagonist, can interfere with the body's ability to regulate sodium levels, leading to hyponatremia.
Serious Consequences of Hyponatremia: Low sodium levels can disrupt vital bodily functions, potentially causing neurological symptoms, seizures, and even coma.
Need for Prompt Intervention: Early detection and correction of hyponatremia are essential to prevent adverse outcomes.
Monitoring and Management: The nurse should assess the patient's sodium level, monitor for signs and symptoms of hyponatremia, and initiate appropriate interventions as needed, such as fluid restriction or electrolyte replacement.
Choice D rationale:
Hepatitis Viral Study (HAA) results are essential for determining the patient's hepatitis A status. Hepatitis A is a highly contagious liver infection that can cause significant illness. Fluoxetine, the other medication the patient is taking, can potentially cause liver damage in rare cases. Therefore, it's crucial to ensure that the patient does not have hepatitis A before initiating or continuing Fluoxetine therapy.
Rationale for Immediate
Potential Liver Injury: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has a rare but potential risk of hepatotoxicity (liver damage).
Hepatitis A Risk: Hepatitis A infection can further exacerbate liver injury, increasing the risk of complications.
Baseline Assessment: HAA results provide information about the patient's hepatitis A status, aiding in risk assessment and management decisions.
Monitoring and Precautions: If the patient tests positive for hepatitis A, the nurse should initiate appropriate precautions to prevent transmission and closely monitor liver function during Fluoxetine therapy.
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