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 D
Explanation
Choice A rationale:
Placing a client in restraints should be a last resort, as it can be traumatizing and can escalate agitation.
Restraints can also cause physical injury and psychological distress.
They should only be used when there is an immediate risk of harm to the client or others.
Choice B rationale:
Haloperidol is an antipsychotic medication that can be used to calm agitated clients.
However, it should not be the first-line intervention, as it can have significant side effects, including drowsiness, dizziness, and muscle stiffness.
It is important to assess the client's individual needs and risks before administering haloperidol.
Choice C rationale:
Asking a client to talk about their feelings can be helpful in some situations, but it is not appropriate when a client is agitated and yelling.
The client is likely to be too overwhelmed to engage in meaningful conversation.
It is important to first de-escalate the situation and ensure the safety of everyone involved.
Choice D rationale:
Moving the client to a seclusion room with continuous observation is the most appropriate intervention in this situation.
This will provide the client with a safe and quiet space to calm down.
It will also allow staff to monitor the client closely and intervene if necessary.
Continuous observation is essential to ensure the client's safety and to prevent self-harm.
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