A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

Develop a flexible crisis intervention plan.

Identify the cause of the anxiety.

Validate the client’s feelings.

Establish rapport with the client.

Avoid eye contact to prevent escalation of anxiety.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Developing a flexible crisis intervention plan is essential in managing a client’s anxiety crisis. Flexibility allows the nurse to adapt the plan to the client’s changing needs and circumstances, ensuring that the interventions remain effective and appropriate.

Choice B reason:

Identifying the cause of the anxiety is crucial for effective intervention. Understanding the underlying factors contributing to the client’s anxiety helps the nurse address the root of the problem and develop targeted strategies to alleviate the client’s distress.

Choice C reason:

Validating the client’s feelings is an important therapeutic technique. It helps the client feel understood and supported, which can reduce anxiety and build trust between the client and the nurse. Validation acknowledges the client’s emotions without judgment.

Choice D reason:

Establishing rapport with the client is fundamental in any therapeutic relationship. Building rapport fosters trust and open communication, which are essential for effective crisis intervention. A strong therapeutic relationship can help the client feel more secure and supported.

Choice E reason:

Avoiding eye contact is not recommended as it can be perceived as dismissive or disinterested. Maintaining appropriate eye contact shows that the nurse is engaged and attentive, which can help reassure the client and reduce anxiety. It is important to balance eye contact to avoid making the client feel uncomfortable.

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Correct Answer is A

Explanation

The correct answer is A.
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.

A. “That is very interesting. We are not sure why people start to isolate themselves.” B. “Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning.” C. “Do you think of yourself as more of an introvert? That makes a difference with how you socialize.” D. “Were you avoiding your friend so that you could hear the voices more clearly?”

Correct Answer is B

Explanation

Choice A reason:

“That is very interesting. We are not sure why people start to isolate themselves.” This response is vague and does not provide the client with useful information. It may leave the client feeling uncertain and unsupported.

Choice B reason:

“Before symptoms of schizophrenia begin, people often isolate themselves. This is an early warning.” This response is informative and helps the client understand that social withdrawal can be an early sign of schizophrenia. It provides a clear explanation and validates the client’s experience.

Choice C reason:

“Do you think of yourself as more of an introvert? That makes a difference with how you socialize.” This response shifts the focus to the client’s personality rather than addressing the specific concern about social withdrawal related to schizophrenia. It may not provide the clarity the client is seeking.

Choice D reason:

“Were you avoiding your friend so that you could hear the voices more clearly?” This response is speculative and could be perceived as judgmental. It does not address the underlying issue of social withdrawal as an early symptom of schizophrenia.

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A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

Correct Answer is A

Explanation

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, “My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?” Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?