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 D
Explanation
A full bladder can help improve the quality of an abdominal ultrasound by pushing the intestines out of the way and providing a clearer view of the uterus and baby.
Correct Answer is A
Explanation
This response acknowledges the client's request for the forms while also addressing the need to discuss the client's decision to leave treatment. It provides an opportunity for the nurse to explore the client's reasons for wanting to leave, discuss the potential consequences of leaving against medical advice, and address any concerns or fears the client may have about continuing treatment.
Option b is not appropriate because it does not address the potential risks associated with leaving treatment against medical advice.
Option c is also not appropriate because it does not acknowledge the client's request and is potentially misleading.
Option d is not appropriate because it does not address the client's reasons for wanting to leave or the potential consequences of leaving against medical advice.
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