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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:

A teenager who refuses to participate in the planned therapy does not necessarily meet the criteria for involuntary commitment. Refusal to participate in therapy can be addressed through other means, such as motivational interviewing or adjusting the treatment plan to better engage the client.

Choice B reason:

A 24-year-old client who refuses to take the prescribed medication also does not automatically qualify for involuntary commitment. Non-compliance with medication can be managed through education, support, and exploring the reasons behind the refusal. Involuntary commitment is typically reserved for situations where the client poses a danger to themselves or others.

Choice C reason:

A 45-year-old client who is homeless and has been diagnosed with a mental disorder may need support and resources, but homelessness and a mental health diagnosis alone do not justify involuntary commitment. The focus should be on providing housing and mental health services rather than involuntary hospitalization.

Choice D reason:

An elderly client who is confused, screaming obscenities in the street, and disturbing neighbors is exhibiting behavior that may pose a risk to themselves or others. This situation suggests a level of acute distress or potential danger that could warrant involuntary commitment to ensure the client’s safety and provide necessary treatment.

A. Anticipate removing the restraints every 4 hours. B. Secure the restraints to the lowest bar of the side rail. C. Secure the restraints using a quick-release tie. D. Ensure four fingers fit under the restraints to prevent constriction.

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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A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

Correct Answer is D

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

When describing the continuum of care for mental health, which would the nurse identify as the primary goal?

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?