A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Allow the client to pace alone until physically tired.

Walk with the client at a gradually slowing pace.

Ask a small group of other clients to walk with the client.

Calmly instruct the client to stop pacing and sit in the dayroom.

Answer and Explanation

The Correct Answer is B

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

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Correct Answer is C

Explanation

If a client reports acute anxiety, the nurse's first priority should be to remain with the client. The nurse should provide a safe, supportive environment for the client and help the client feel less anxious. This can be accomplished by staying with the client, listening attentively to the client, and offering reassurance and support. Options A and D are appropriate actions to take when caring for a client with anxiety, but they are not the first priority.

Option B may be an appropriate intervention when caring for a client with anxiety, but it is not the first priority.

A. The child was brought to the facility 30 min after the injury occurred. B. The child begins to cry when her arm is examined by the provider. C. The parents report that the child injured herself by falling off the couch. D. The child's examination shows a single injury.

Correct Answer is C

Explanation

The parents report that the child injured herself by falling off the couch.

A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.

Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.

Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.

Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.

Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.

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A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports acute anxiety. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?

Correct Answer is C

Explanation

A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

A nurse is discussing insomnia management techniques with a group of clients who have anxiety disorders. Which of the following techniques mentioned by a client requires further teaching?

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

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