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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Individuals with OCD often engage in compulsive behaviors as a way to reduce anxiety or distress. In this case, the client’s behavior of constantly picking up after others in the day room may be a compulsion that helps them decrease their anxiety to a tolerable level.

A. Avoid discussing past manipulative behaviors with the client. B. Allow manipulation so as to not raise the client's anxiety. C. Institute consequences for manipulative behavior D. Avoid discussing present behaviors with the client

Correct Answer is C

Explanation

Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not eﬀectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.

Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.

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A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A registered nurse is caring for a client who has been diagnosed with obsessive-compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

Correct Answer is A

Explanation

A registered nurse is planning to care for a client who demonstrates manipulative behaviors. Which of the following interventions should be included in the plan of care?

Correct Answer is C

Explanation

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