A nurse is caring for a client who is has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the fleer continually. Which of the following actions should the nurse take first?

Tell the client you will remain with her.

Take the client to a quiet rooms.

Ask the client what precipitated this anxiety

offer the client a prescribed anxiety medication

Answer and Explanation

The Correct Answer is A

A: Providing reassurance of presence can help stabilize the client's emotional state by ensuring safety and support.
B: While taking the client to a quiet room can be helpful, the first action should be to reassure her of your presence and support.

C: Inquiring about the cause of anxiety can be useful, but it should not be the first step when the client is actively hyperventilating.
D: Medication might be necessary, but initial reassurance and creating a safe environment take precedence.

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Correct Answer is C

Explanation

A: Checking the bruises at the next visit does not address the immediate safety concerns of the client.
B: Instituting more frequent visits might help in monitoring but doesn't address the immediate issue of suspected abuse.
C: Reporting suspected abuse as per agency guidelines is the most immediate and appropriate action to ensure the client’s safety.
D: Family therapy might be helpful later but does not immediately address or confirm the suspected abuse.

A. Important to the client B. Evaluated on a weekly basis C. Achievable by client discharge D. Approved by the physician

Correct Answer is A

Explanation

A: Goals must be relevant and important to the client to encourage engagement and commitment to the therapeutic process.
B: While regular evaluations are essential, they must align with the individual’s progress and specific needs rather than a set schedule.

C: Goals should indeed be achievable, but tying them strictly to discharge may not accommodate ongoing or long-term needs.
D: While physician input can be valuable, goals should be client-centered and driven by nursing assessments and the therapeutic plan.

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A nurse is caring for a client who is has an anxiety disorder and who has begun to hyperventilate, wring her hands, and is pacing the fleer continually. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

In developing a nursing care plan for an adult with a mental health disorder, the nurse knows the goals that are set must be:

Correct Answer is A

Explanation

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