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 D

Explanation

Choice A rationale:

Sweating is not an adverse effect commonly associated with buspirone (Buspar). While some side effects like dizziness, nausea, and headache might occur, sweating is not typically reported as a significant adverse effect of this medication.

Choice B rationale:

Decreased appetite is a potential adverse effect of buspirone (Buspar). However, it is not the most concerning in this context. Anxiety disorders like generalized anxiety disorder can lead to appetite changes, and while this should be monitored, it is not a priority compared to more severe adverse effects.

Choice C rationale:

Discolored urine is not a common adverse effect of buspirone (Buspar). Buspirone is primarily used to treat anxiety and does not usually cause changes in urine color. This effect is unrelated to the medication and likely has a different underlying cause.

Choice D rationale:

Hallucinations are a concerning adverse effect that should be reported to the provider. Hallucinations are not a typical side effect of buspirone and might indicate a more serious issue or an interaction with other medications. Reporting this symptom promptly is crucial to ensuring the client's safety and well-being.

A. "You should not feel guilty about your daughter's diagnosis. Schizophrenia is unpreventable.” B. "You said that you feel guilty about your daughter's diagnosis. Let's talk about what is causing you to feel this way.” C. "Your provider has explained the causes of schizophrenia. Why do you feel guilty about your daughter's diagnosis?” D. "I'm sure your daughter's diagnosis is very difficult to deal with, but everything will be all right once she receives the proper treatment.”

Correct Answer is B

Explanation

Choice A rationale:

Telling the parents that they should not feel guilty might invalidate their emotions and discourage open communication. It's essential to acknowledge their feelings and address them empathetically.

Choice B rationale:

This choice demonstrates therapeutic communication and empathy. It encourages the parents to express their feelings, and the nurse is offering to listen and explore the reasons behind their guilt.

Choice C rationale:

This statement seems confrontational and may discourage the parents from sharing their emotions openly. Asking why they feel guilty immediately might put them on the defensive.

Choice D rationale:

While this statement acknowledges the difficulty of the situation, it ends with a premature reassurance that may not be well-received. The parents need space to discuss their feelings before focusing on the future.

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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 taking care of a client who has generalized anxiety disorder and is taking buspar (Buspirone). Which of the following adverse effects should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for an adolescent client who has a new diagnosis of schizophrenia. The client's parents are tearful and express feelings of guilt. Which of the following is an appropriate statement by the nurse?

Correct Answer is B

Explanation

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

A nurse is caring for a client who lost all his possessions in a house fire and states, "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take?

A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

The nurse is assessing a client in group therapy on which type of techniques for modifying behaviors would be most appropriate. The nurse has decided to use covert sensitization. Which of the following statementbest describes this type of therapy?