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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Is an aversion therapy that produces unpleasant consequences for undesirable behavior.
Choice A rationale:
Decreases or eliminates a behavior by introducing a more adaptive behavior that is incompatible with the unacceptable behavior. Choice A refers to the technique of "differential reinforcement," where an undesirable behavior is replaced by a more appropriate behavior. This technique involves reinforcing positive behaviors while ignoring or providing minimal attention to negative behaviors. It is not the same as covert sensitization.
Choice B rationale:
Is an aversion therapy that produces unpleasant consequences for undesirable behavior. Covert sensitization is a form of aversion therapy used to eliminate unwanted behaviors by associating them with unpleasant imagery or thoughts. It's based on the principle that if a person can associate a negative response with a certain behavior, they will be less likely to engage in that behavior. This technique is used for behaviors like addiction or certain compulsive behaviors.
Choice C rationale:
An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. Choice C refers to "time-out," a technique used to decrease undesirable behaviors by removing the individual from the environment where the behavior is occurring. This is often used with children and involves giving them a brief break from a situation to help them calm down. It's not the same as covert sensitization.
Choice D rationale:
Relies on an individual's imagination rather than medication for unpleasant symptoms. Choice D is not directly related to covert sensitization. Covert sensitization involves creating a negative association with a behavior using mental imagery. It's not about relying on imagination instead of medication.
Correct Answer is B
Explanation
The correct answer is choice: B. Sibling position.
Choice A rationale:
Marital skew is not a concept associated with Bowen's family systems theory. It does not correspond to any recognized pattern in this theoretical approach.
Choice B rationale:
Sibling position is an important concept in Bowen's family systems theory. It refers to the birth order of siblings within a family and how this birth order can influence the roles and dynamics within the family unit.
Choice C rationale:
Pseudomutuality is not a concept of Bowen's family systems theory. This term does not align with the terminology or principles of this theoretical approach.
Choice D rationale:
Double-bind communication is a concept introduced by Gregory Bateson and is associated with the communication patterns within dysfunctional families. While it is related to family interactions, it is not specifically attributed to Bowen's theoretical approach.
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