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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Admission to a locked inpatient psychiatric unit is a more restrictive environment. While necessary for some clients, it limits their freedom and autonomy. The least restrictive environment principle seeks to avoid such settings unless absolutely necessary.
Choice B reason:
Placement in a secured padded room is highly restrictive and typically used only in extreme cases where the client poses an immediate danger to themselves or others. This setting is far from the least restrictive environment.
Choice C reason:
Involuntary commitment to an outpatient community mental health center represents a less restrictive environment. It allows the client to receive necessary treatment and support while remaining in the community, maintaining a higher level of independence and normalcy.
Choice D reason:
Medication administration for sedation to the point where the client cannot get out of bed is a highly restrictive intervention. It significantly limits the client’s autonomy and is not aligned with the principle of providing care in the least restrictive environment.
Correct Answer is C
Explanation
Choice A reason:
Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.
Choice B reason:
Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.
Choice C reason:
Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.
Choice D reason:
Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.
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