A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

"Come with me to an area where we can talk without interruption."

"Providers usually recommend relaxation exercises for clients who are as upset as you are."

"An antianxiety pill works best for situations like this."

"Most clients with anxiety issues benefit from lying down.".

Answer and Explanation

The Correct Answer is A

The correct answer is choice A: "Come with me to an area where we can talk without interruption."

Choice A rationale:

The nurse's response of inviting the client to a quieter area for conversation demonstrates therapeutic communication. By offering a private space, the nurse acknowledges the client's distress and creates an environment conducive to open discussion. This response allows the client to express their feelings without the pressure of being observed or interrupted, fostering a sense of safety and trust.

Choice B rationale:

This response suggests recommending relaxation exercises, which might not be appropriate for a client in a heightened state of anxiety. While relaxation techniques can be helpful for managing anxiety, the client's current level of distress requires immediate attention and active engagement rather than advice on future interventions.

Choice C rationale:

Mentioning an antianxiety pill oversimplifies the situation and ignores the importance of therapeutic communication. Medication is not the primary intervention at this moment, and assuming that a pill would be the immediate solution could diminish the client's need to express their feelings and concerns.

Choice D rationale:

Suggesting that most clients with anxiety issues benefit from lying down is an inaccurate generalization. Different individuals have varying coping mechanisms, and the client's pacing and rambling indicate a need for active support and conversation, rather than a one-size-fits-all approach of lying down.

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Correct Answer is B

Explanation

Choice A rationale:

Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.

Choice B rationale:

Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.

Choice C rationale:

Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.

Choice D rationale:

Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.

A. Risperidone (Risperdal). B. Lithium carbonate (Eskalith). C. Disulfiram (Antabuse). D. Methadone (Methadose).

Correct Answer is D

Explanation

Choice A rationale:

Risperidone (Risperdal) is an atypical antipsychotic commonly used to manage symptoms of schizophrenia and bipolar disorder. It is not indicated for opioid withdrawal, making it an inappropriate choice.

Choice B rationale:

Lithium carbonate (Eskalith) is a mood stabilizer used primarily for bipolar disorder. It has no direct impact on opioid withdrawal symptoms, so it would not be the correct choice for managing opioid withdrawal.

Choice C rationale:

Disulfiram (Antabuse) is used to deter alcohol consumption by inducing unpleasant reactions when alcohol is consumed. It is not used to manage opioid withdrawal symptoms and is therefore not the correct choice.

Choice D rationale:

Methadone (Methadose) is a synthetic opioid agonist often used in medication-assisted treatment for opioid dependence and withdrawal. It helps alleviate withdrawal symptoms and cravings, promoting a smoother and safer withdrawal process.

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A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches, the client states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse is caring for a client who is withdrawing from opioids. Which of the following medications would the nurse prepare to administer?

Correct Answer is D

Explanation

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

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A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?

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