A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:
Put the client in a quiet room
Teach the client deep breathing
Remain with the client
Encourage the client to talk about their feelings and concerns
The Correct Answer is C
Choice A reason:
Putting the client in a quiet room can help reduce external stimuli and may be beneficial in managing anxiety. However, it does not address the immediate need for support and reassurance. The presence of a nurse can provide a sense of safety and help the client feel more secure during a highly anxious state.
Choice B reason:
Teaching the client deep breathing techniques is an effective strategy for managing anxiety. However, in the immediate aftermath of a traumatic event, the client may not be able to focus on learning new techniques. Providing immediate support and reassurance is more critical at this stage.
Choice C reason:
Remaining with the client is the most appropriate immediate intervention. The nurse’s presence can provide comfort, reassurance, and a sense of safety, which are crucial in managing acute anxiety. This approach helps to stabilize the client and allows for further assessment and intervention once the client is calmer.
Choice D reason:
Encouraging the client to talk about their feelings and concerns is an important part of anxiety management, but it may not be the best immediate intervention in a severe state of anxiety. Initially, the client may need more direct support and reassurance before they are able to articulate their feelings effectively. Once the client is calmer, discussing their feelings can be beneficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
Recent marriage is generally considered a protective factor against suicide rather than a risk factor. Marriage can provide emotional support and stability, which can reduce the risk of suicidal behavior. However, the quality of the relationship and other individual factors should also be considered.
Choice B reason:
Age greater than 55 is a recognized risk factor for suicide, particularly among men. Older adults may face multiple stressors such as chronic illness, loss of loved ones, and social isolation, which can increase the risk of suicide. It is important to monitor and support older adults who may be at risk.
Choice C reason:
Having a bachelor’s degree is not typically associated with an increased risk of suicide. In fact, higher educational attainment is often linked to better mental health outcomes and access to resources. However, individual circumstances and stressors should always be considered.
Choice D reason:
Male gender is a significant risk factor for suicide. Men are more likely to die by suicide compared to women, although women may attempt suicide more frequently. This gender disparity is attributed to various factors, including the methods used and societal expectations around expressing emotions.
Choice E reason:
A diagnosis of schizophrenia is a known risk factor for suicide. Individuals with schizophrenia may experience severe symptoms, including delusions and hallucinations, which can contribute to suicidal thoughts and behaviors. It is crucial to provide comprehensive care and support to individuals with this diagnosis to mitigate the risk of suicide.
Correct Answer is C
Explanation
Choice A reason:
Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.
Choice B reason:
Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.
Choice C reason:
Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.
Choice D reason:
Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.
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