A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
Assist the client with relaxation techniques in the group.
Escort the client from the group to reduce stimuli.
Provide education about ways to cope with anxiety.
Ask the client to describe and identify the source of the feelings.
The Correct Answer is A
Choice A rationale:
Assisting the client with relaxation techniques within the group is an appropriate and immediate intervention for managing severe anxiety. This approach can help the client regulate their anxiety levels and provide a sense of support in the therapeutic environment.
Choice B rationale:
Escorting the client from the group to reduce stimuli may be considered if the client's anxiety becomes overwhelming and they cannot manage it within the group setting. However, it is generally preferable to try in-group interventions first.
Choice C rationale:
Providing education about ways to cope with anxiety is valuable, but it may not be the most effective intervention in the moment when the client is already experiencing severe anxiety. Practical techniques should be initiated first.
Choice D rationale:
Asking the client to describe and identify the source of the feelings may be a useful therapeutic technique in individual therapy sessions but may not be the best immediate intervention during a group therapy session when the focus is on managing acute anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.
Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.
Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.
Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.
Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.
Correct Answer is ["C","D","E","F","G"]
Explanation
Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.
Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.
Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.
Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.
Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.
Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.
Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.
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