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 C
Explanation
Choice A reason:
Honking the car horn to get the client’s attention could startle the client and potentially escalate the situation. It is important to avoid actions that could provoke a violent response or increase the client’s agitation. Safety is the primary concern, and honking the horn does not ensure the nurse’s or the client’s safety.
Choice B reason:
Stopping the car in the client’s driveway and calling the authorities is not the safest immediate action. While calling the authorities is necessary, stopping in the driveway could put the nurse in a vulnerable position. It is safer to move away from the immediate vicinity before making the call.
Choice C reason:
Keeping driving in a path that is going away from the client’s house is the safest immediate action. This ensures the nurse’s safety by creating distance from the potentially dangerous situation. Once at a safe distance, the nurse can then call the authorities to handle the situation appropriately.
Choice D reason:
Calmly speaking the client’s name out of the car window could also escalate the situation. The client may perceive this as a threat or intrusion, leading to unpredictable behavior. It is safer to avoid direct interaction and ensure personal safety first.
Correct Answer is C
Explanation
Choice A reason:
Bizarre behavior is considered a positive symptom of schizophrenia. Positive symptoms are those that add abnormal experiences, such as hallucinations, delusions, and disorganized behavior. Bizarre behavior falls into this category as it represents an addition to normal behavior patterns.
Choice B reason:
Somatic delusions are also positive symptoms of schizophrenia. These delusions involve false beliefs about the body, such as believing one has a serious illness despite medical evidence to the contrary. Positive symptoms are characterized by the presence of abnormal thoughts or behaviors.
Choice C reason:
Affective flattening is a negative symptom of schizophrenia. Negative symptoms are characterized by the absence or reduction of normal functions, such as emotional expression, motivation, and social interaction. Affective flattening refers to a lack of emotional expression, where the individual shows little to no facial expressions or emotional responses.
Choice D reason:
Illogicality, or disorganized thinking, is considered a positive symptom of schizophrenia. It involves incoherent or nonsensical speech and thought patterns. Positive symptoms are those that reflect an excess or distortion of normal functions.
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