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 A

Explanation

Choice A rationale:

Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that can occur as a severe adverse effect of antipsychotic medications, such as risperidone (Risperdal). Symptoms of NMS include flu-like symptoms (fever, muscle rigidity, and sweating) along with altered mental status, and autonomic dysregulation. It's crucial for the nurse to recognize this potentially fatal condition promptly and intervene appropriately.

Choice B rationale:

Tardive dyskinesia is a movement disorder that is often a result of long-term use of antipsychotic medications, but it is characterized by repetitive, involuntary movements of the face and other body parts. It doesn't typically present with flu-like symptoms or low blood pressure.

Choice C rationale:

Acute dystonia is characterized by involuntary muscle contractions and spasms, often involving the muscles of the face, neck, and back. It usually occurs shortly after starting antipsychotic treatment. While it can cause discomfort, it doesn't present with flu-like symptoms and low blood pressure as described in the scenario.

Choice D rationale:

Pseudoparkinsonism, also known as drug-induced parkinsonism, is characterized by symptoms similar to Parkinson's disease, such as tremors, bradykinesia (slowness of movement), and rigidity. It doesn't typically cause flu-like symptoms and low blood pressure.

A. The client joined a bowling league 2 months ago. B. The client meets his daughter for dinner every week. C. The client has kept his partner's closet untouched since her death. D. The client exercises at a local health facility 3 days each week.

Correct Answer is C

Explanation

Choice A rationale:

Joining a bowling league 2 months ago indicates that the client is actively seeking social interactions and engaging in activities. While grief can manifest in various ways, joining a social activity does not necessarily indicate maladaptive grief. It's important for individuals to find ways to connect with others and continue living their lives after the loss of a loved one.

Choice B rationale:

Meeting his daughter for dinner every week demonstrates ongoing communication and emotional connection with family. This behavior suggests a healthy attempt at maintaining relationships and coping with the loss. Regular interactions with family members can be supportive during the grieving process.

Choice C rationale:

Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests an inability to let go of personal belongings and move forward after a significant period of time. In healthy grieving, individuals usually work through their emotions and gradually start reorganizing their living spaces and personal items.

Choice D rationale:

Exercising at a local health facility 3 days each week indicates that the client is engaging in self-care and maintaining physical health. While exercise can be a coping mechanism, this behavior alone does not provide enough evidence to determine whether the client is experiencing maladaptive grief.

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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

Correct Answer is A

Explanation

A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate that the client is experiencing maladaptive grief?

Correct Answer is C

Explanation

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