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 C
Explanation
During the termination phase of the nurse-client relationship, the nurse should focus on making appropriate referrals to ensure that the client continues to receive the care and support they need after the relationship with the nurse has ended.
Option a. Developing realistic solutions is an important task during the working phase of the nurse-client relationship, when the nurse and client work together to identify and implement solutions to the client’s problems.
Option b. Building rapport and trust is an important task during the orientation phase of the nurse-client relationship, when the nurse and client get to know each other and establish a therapeutic relationship.
Option d. Identifying expected outcomes is an important task during the planning phase of the nursing process, when the nurse and client work together to set goals and develop a plan of care.
Correct Answer is A
Explanation
Agoraphobia is an anxiety disorder characterized by the fear or avoidance of situations or places where escape might be difficult or help may not be available in the event of a panic attack or other distressing symptom. Individuals with agoraphobia may have intense anxiety or panic symptoms in places such as crowded areas, enclosed spaces, public transportation, open spaces, or places far away from home.
Option b refers to social anxiety disorder.
Option c refers to specific phobia.
Option d refers to obsessive-compulsive disorder.
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