During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Ask the client why she is so anxious.

Administer a PRN sedative to help relieve anxiety.

Assist the client in developing alternative coping skills.

Remain calm and use a matter-of-fact approach.

Answer and Explanation

The Correct Answer is D

A) Asking the client why she is so anxious might seem like a valid approach to understand her feelings; however, at this moment, she may not be able to articulate her anxiety effectively. Instead of exploring the reasons for her anxiety right away, it's more important to provide immediate support.

B) Administering a PRN sedative can provide temporary relief for severe anxiety, but it should not be the first line of intervention during the admission process. Pharmacological intervention is important, but establishing a therapeutic relationship and using non-pharmacological approaches can be equally or more effective in the long term.

C) Assisting the client in developing alternative coping skills is a valuable intervention, but it may not be appropriate to initiate this process immediately during the admission phase when the client is experiencing acute anxiety. The client needs first to feel safe and stabilized.

D) Remaining calm and using a matter-of-fact approach is the most important intervention during the admission process. This approach helps create a safe environment and reassures the client. By modeling calmness, the nurse can help reduce the client’s anxiety levels and foster a sense of security, allowing for better engagement and assessment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A) Disrupting group activities indicates behavioral issues, but it alone does not necessarily warrant constant observation. While disruptive behavior can be concerning, it may not pose an immediate risk to the client or others.

B) Talking with nonsensical words suggests disorganized thinking or possible psychosis, which is important to note. However, this behavior does not by itself indicate that the client is in immediate danger or that they require constant observation.

C) Refusing antipsychotic medications is a significant factor, particularly in managing the client's mental health. However, refusal of medication does not automatically necessitate constant observation unless it leads to behaviors that put the client or others at risk.

D) Wandering into clients' rooms is the most concerning behavior in this context. This action can pose a risk to both the individual and other clients, potentially leading to boundary violations or safety issues. Constant observation is warranted to ensure the safety of all clients and to manage the individual's behavior effectively.

A. Reason for the suicide attempt. B. The drug that was ingested. C. The time since drug ingestion. D. Past history of depression.

Correct Answer is B

Explanation

A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.

B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.

C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.

D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is D

Explanation

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

Correct Answer is B

Explanation

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

An employee with a history of hypertension, visits the employee clinic weekly for blood pressure checks. During the assessment the client reports being upset with coworkers and would like to shoot them. Which action should the nurse take first?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?