A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Identifying the client's coping skills.

Protecting the client from injury to himself.

Determining the cause of the client's anxiety.

Ensuring that the client feels safe.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

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Correct Answer is C

Explanation

Choice A rationale:

Praying and using relaxation techniques when experiencing rapid breathing are effective stress management strategies. These techniques help manage the body's stress response and promote relaxation.

Choice B rationale:

Journaling is a constructive way to manage stress, especially when verbal expression is difficult. It allows individuals to reflect on their thoughts and emotions, leading to a sense of relief.

Choice C rationale:

"Fixing a pot of coffee" when anxious is the least effective technique mentioned. Consuming large amounts of caffeine can exacerbate anxiety symptoms by increasing heart rate and contributing to a sense of restlessness and nervousness.

Choice D rationale:

Engaging in physical exercise when experiencing tension in the neck is a productive strategy. Exercise promotes the release of endorphins, which are natural mood lifters and stress reducers.

A. Approach the client frequently throughout the day for brief interactions. B. Disclose some personal information to the client to demonstrate approachability. C. Adopt a neutral attitude when providing care. D. Wait for the client to initiate interaction.

Correct Answer is C

Explanation

Choice A rationale:

Approaching the client frequently throughout the day for brief interactions might exacerbate the client's suspiciousness and discomfort. Individuals who are extremely suspicious may interpret frequent approaches as intrusive or manipulative, leading to increased agitation or withdrawal.

Choice B rationale:

Disclosing personal information to the client in an attempt to demonstrate approachability is not recommended. Sharing personal information can blur professional boundaries and may not necessarily address the client's suspicion. It's important to build trust gradually through consistent, respectful, and professional interactions.

Choice C rationale:

Adopting a neutral attitude when providing care is appropriate because it helps create a non-threatening environment. Individuals who are suspicious may interpret overly friendly or emotionally charged behavior as insincere or manipulative. A neutral and respectful approach allows the client to feel more comfortable and safe in the nurse's presence.

Choice D rationale:

Waiting for the client to initiate interaction may not be effective in establishing a therapeutic relationship. Extremely suspicious clients might be hesitant to initiate interactions due to their mistrust. Nurses should take the initiative to approach clients with suspicion in a respectful and neutral manner to gradually build rapport and trust.

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A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?

Correct Answer is C

Explanation

A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?

Correct Answer is C

Explanation

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