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 C

Explanation

This statement shows that the client is not accepting the reality of their prognosis and is dismissing the doctor's professional opinion. Denial is a common stage in the grief process where individuals may refuse to believe or accept a difficult reality, often as a coping mechanism to avoid the pain and sadness of the situation. Options a, b, d, and e do not indicate denial and instead may suggest fatigue, acceptance, physical weakness, and anger or frustration, respectively.

A. The client experienced a common side eﬀect to the medication. B. The client consumed alcohol while taking the medication. C. The client demonstrated an allergic response to the medication. D. The client took an overdose of the medication.

Correct Answer is B

Explanation

Disulfiram is a medication used in the treatment of alcohol addiction. It works by causing unpleasant symptoms, such as nausea and vomiting, when alcohol is consumed. This medication is only eﬀective if the client abstains from alcohol consumption while taking it. If the client consumes alcohol while taking disulfiram, they will experience severe adverse eﬀects, including nausea and vomiting, which can be a sign of a severe reaction. Therefore, it is crucial for the nurse to suspect that the client's distress is likely caused by consuming alcohol while taking disulfiram.

Option a is incorrect because nausea and vomiting are not common side eﬀects of disulfiram.

Option c is incorrect because the question does not provide any information suggesting an allergic reaction.

Option d is incorrect because an overdose of disulfiram would not likely cause nausea and vomiting as severe as those reported by the client.

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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 nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

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Explanation

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