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","E","F"]
Explanation
Choice A reason:
Impaired interpersonal relationships can be a consequence of schizophrenia, but it is not a specific diagnostic criterion in the DSM-5. The criteria focus on more direct symptoms of the disorder.
Choice B reason:
Inability to initiate activities may be related to negative symptoms of schizophrenia, such as avolition, but it is not explicitly listed as a diagnostic criterion in the DSM-5. The criteria include more specific symptoms like disorganized behavior and hallucinations.
Choice C reason:
Disorganized behavior is one of the core symptoms of schizophrenia according to the DSM-5. It includes behaviors that are inappropriate or not goal-directed, reflecting a disruption in normal functioning.
Choice D reason:
Antisocial personality is a separate diagnosis and not a criterion for schizophrenia. Schizophrenia and antisocial personality disorder are distinct conditions with different diagnostic criteria.
Choice E reason:
Hallucinations are a key symptom of schizophrenia. They involve perceiving things that are not present, such as hearing voices or seeing things that others do not see. Hallucinations are one of the primary positive symptoms of schizophrenia.
Choice F reason:
Lack of emotional expression, also known as affective flattening, is a negative symptom of schizophrenia. It involves a reduced ability to express emotions and is a significant criterion in the diagnosis of schizophrenia.
Correct Answer is B
Explanation
Choice A reason:
Neuroleptic malignant syndrome (NMS) is a rare but serious side effect of antipsychotic medications. It is characterized by symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction. The client’s description of needing to move around does not align with the symptoms of NMS.
Choice B reason:
Akathisia is a common side effect of first-generation antipsychotic medications. It is characterized by a feeling of inner restlessness and an urgent need to move. The client’s behavior of pacing and the statement “I just need to move around” are indicative of akathisia.
Choice C reason:
Tardive dyskinesia is a long-term side effect of antipsychotic medications, characterized by involuntary, repetitive movements, particularly of the face and tongue. The client’s symptoms of needing to move around do not match the typical presentation of tardive dyskinesia.
Choice D reason:
Impaired ability to regulate body temperature can occur with antipsychotic medications, but it is not characterized by the need to move around. The client’s symptoms are more consistent with akathisia rather than issues with thermoregulation.
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