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: 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.

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is C

Explanation

Answer: c. Document the client's verbatim statements.

Here's why the other options are wrong:

a. Ask the client for permission to take photographs:While photographs may be collected as evidence later, it should not be the first priority. The priority is to focus on patient care and emotional well-being.
b. Provide community sexual assault support contacts:Offering support resources is important, but documenting the details of the assault is crucial for forensic and legal purposes, and should come first.
d. Determine any physical signs of injury:Looking for physical injuries is important, but documenting the client's account should come first. This ensures the client's narrative is captured accurately and can be referred to later.

Documenting the client's verbatim statements is the most important initial action because:

It preserves the client's account of the assault in their own words.
It allows for accurate reporting and investigation.
It can be used as evidence in legal proceedings.

Here are some supporting points:

The Rape, Abuse & Incest National Network (RAINN):"Law enforcement will need to take a detailed statement about the assault, and a medical professional will likely perform a physical exam. Be prepared to answer questions about what happened." [1]
The National Sexual Assault Hotline:"Law enforcement will want to get a statement from you as soon as possible after the assault. Try to remember the details of the assault as clearly as you can." [2]

In conclusion, while all the other options are important aspects of caring for a sexual assault survivor, documenting the client's verbatim statements is the most critical initial action for a nurse to take in the emergency department setting.

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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

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?

Correct Answer is B

Explanation

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse on an inpatient mental health unit is admitting a client who has panic-level anxiety. After orienting the client to his room, which of the following nursing actions is most therapeutic at this time?

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