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 B

Explanation

The correct answer is choice B. "It sounds like you're having a difficult time."

Choice A rationale:

"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.

Choice B rationale:

"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.

Choice C rationale:

"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.

Choice D rationale:

"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.

A. "I know that men who are abusers gain power through intimidation.” B. "I have heard that abusers think of themselves as important and have high self-esteem.” C. "I know that abusers lack social supports and social skills.” D. "I have heard that abusers try to keep their partner isolated from others.”

Correct Answer is B

Explanation

Choice A rationale:

The statement "I know that men who are abusers gain power through intimidation." is accurate and aligned with the understanding of domestic violence dynamics. Abusers often use intimidation tactics to exert control over their victims, perpetuating a cycle of power and control.

Choice B rationale:

The statement "I have heard that abusers think of themselves as important and have high self-esteem." needs clarification. This statement is not entirely accurate. Abusers may display a façade of high self-esteem, but beneath it, they often have deep-seated insecurities. It's important to highlight that abusive behavior stems from a desire to control and dominate, rather than genuine self-worth.

Choice C rationale:

The statement "I know that abusers lack social supports and social skills." is inaccurate. Abusers can have social supports and social skills. Domestic violence is not solely determined by the lack of social skills or support; it is a complex issue rooted in power dynamics and learned behaviors.

Choice D rationale:

The statement "I have heard that abusers try to keep their partner isolated from others." is accurate and aligned with the understanding of domestic violence dynamics. Abusers frequently isolate their partners to maintain control over them, making it difficult for victims to seek help or support from others.

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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

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