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.

Answer and Explanation

The Correct Answer is B

A. Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.

B. Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.

C. Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.

D. Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.

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Correct Answer is ["A","C","D","F"]

Explanation

Choice A rationale:
This reflects a potential misunderstanding about the diagnosis and may contribute to stigma. The nurse should provide education and clarify that having acute stress disorder or similar responses to trauma does not mean the client is "crazy."

Choice B rationale:
This statement reflects a positive attitude toward therapy and self-improvement. There is no immediate need for follow-up teaching in this statement, as it aligns with the potential benefits of therapy for coping with trauma.

Choice C rationale:
This indicates the client's interest in holistic approaches, which is positive. However, the nurse should provide information and guidance on the use of such approaches in conjunction with other treatments.

Choice D rationale:
This suggests that the client may believe her response is typical. The nurse should provide education about the variability in individual responses to stress and trauma.

Choice E rationale:
This statement shows an understanding of the relationship between acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). While it's true that having ASD can increase the risk of developing PTSD, this statement does not require immediate follow-up teaching. However, the client should receive ongoing education about managing and preventing PTSD

Choice F rationale:
This raises concerns about the client's expectations regarding the duration of medication. The nurse should provide information about the intended duration of medication and the importance of ongoing assessment and follow-up with healthcare providers.

A. Cancer screening results, anger, gastritis, daily alcohol intake. B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding. C. Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener." D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct Answer is C

Explanation

Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.

Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."

Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.

Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","F"]

Explanation

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is C

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

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The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?