A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?
Encourage verbalization of feelings.
Provide an activity for diversion.
Remain with the client.
Have the client identify two coping skills.
The Correct Answer is C
If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.
Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Moderate. According to the Mayo Clinic moderate anxiety is characterized by symptoms such as loud and rapid speech, difficulty concentrating, restlessness, and increased worry. The client's behavior matches these symptoms, indicating that they are experiencing moderate anxiety.
Choice B. Panic is incorrect because panic is a severe form of anxiety that involves symptoms such as chest pain, shortness of breath, trembling, and a sense of impending doom. The client does not exhibit these symptoms.
Choice C. Severe is incorrect because severe anxiety is marked by symptoms such as irrational fear, detachment from reality, hallucinations, and loss of control¹². The client does not show these symptoms.
Choice D. Mild is incorrect because mild anxiety is associated with symptoms such as nervousness, increased alertness, and slight discomfort¹². The client's symptoms are more intense than mild anxiety.
Correct Answer is B
Explanation
When an assistive personnel expresses concerns or vents about client behaviors, a therapeutic response is necessary. Asking the AP to explain or to further describe his or her thoughts, feelings, or concerns will allow the AP to reflect on these issues and help clarify any misconceptions or misunderstandings. The nurse's response should be nonjudgmental, noncritical, and focused on the AP's perceptions and feelings.
Option A is confrontational and Option C is inappropriate because it suggests that the AP is not spending enough time with the client.
Option D shifts responsibility for managing the client's behavior to the nurse instead of helping the AP reflect on his or her perception of the situation.
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