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 B

Explanation

Choice A reason:
Cognitive therapy focuses on changing negative thought patterns and behaviors through structured sessions with a therapist. While it is an effective treatment for many mental health conditions, it does not involve the structured daily routines described in the scenario. Cognitive therapy is typically conducted in individual or group sessions rather than through the daily activities of an inpatient unit.

Choice B reason:
Milieu therapy involves creating a therapeutic environment that supports the client’s recovery through structured daily routines and interactions with staff and peers. The emphasis on getting up at a certain time, attending meals, and taking medications on schedule is characteristic of milieu therapy. This approach helps clients develop healthy habits, social skills, and a sense of responsibility.

Choice C reason:
Family therapy involves working with the client and their family members to improve communication, resolve conflicts, and support the client’s recovery. While family therapy is an important component of comprehensive mental health care, it does not involve the structured daily routines described in the scenario. Family therapy sessions are typically scheduled separately from the client’s daily activities.

Choice D reason:
Electroconvulsive therapy (ECT) is a medical treatment that involves inducing controlled seizures to alleviate severe psychiatric symptoms. ECT is typically administered in a hospital setting under anesthesia and is not related to the structured daily routines described in the scenario. It is used for specific conditions, such as severe depression or treatment-resistant schizophrenia, and is not a form of therapy that involves daily activities.

A. ELECTROENCEPHALOGRAM (EEG) MONITOR B. OPHTHALMOSCOPE C. CARDIAC MONITOR D. BLOOD PRESSURE MONITOR E. PORTABLE X-RAY MACHINE

Correct Answer is ["A","C","D"]

Explanation

Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.

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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

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Correct Answer is B

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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