A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Identify the clients’ coping skills.
Determine the cause of the client's anxiety.
Ensuring that the client feels safe.
Protecting the client from injury
The Correct Answer is D
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement clearly and accurately conveys the client's complaint of being raped by her date.
Option a uses colloquial language and may not accurately convey the severity and trauma of the situation.
Option c uses vague language that does not clearly state the nature of the incident.
Option d uses subjective language that may not be helpful for accurately documenting the client's complaint.
It's important for healthcare providers to use appropriate language when documenting sensitive situations like sexual assault to ensure clear communication among the healthcare team and accurate documentation for legal and forensic purposes.
Correct Answer is A
Explanation
Clonazepam is a benzodiazepine medication that acts quickly to reduce anxiety and promote relaxation. It is commonly used as a PRN medication for acute anxiety episodes.
Amitriptyline (Elavil) is a tricyclic antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action and potential for side effects.
Olanzapine (Zyprexa) is an atypical antipsychotic medication that can be used to treat anxiety in certain cases, but it is not typically used as a PRN medication for acute anxiety episodes.
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI) antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action. It is usually taken on a daily basis to provide ongoing anxiety relief.
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