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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Aspirin 81 milligrams PO daily is commonly used as a low-dose antiplatelet medication and is generally not concerning in this context, especially with the symptoms described. It does not have a direct impact on blood pressure or the acute symptoms presented.
B) Losartan 50 mg PO daily is an antihypertensive medication used to manage high blood pressure. While the client’s blood pressure is elevated, this medication is appropriate for managing hypertension, and it does not pose an immediate concern.
C) Phenelzine 60 mg PO daily is of the most concern. It is a monoamine oxidase inhibitor (MAOI), which can have serious interactions with certain foods and medications, potentially leading to hypertensive crises, especially given the client’s high blood pressure of 216/108 mmHg. The client’s headache, nausea, and vomiting, combined with elevated vital signs, could indicate such a crisis, making this medication a significant concern.
D) Hydrochlorothiazide 12.5 mg PO daily is a thiazide diuretic commonly used to treat hypertension. While the client’s blood pressure is high, this medication is typically used to lower blood pressure and does not pose an immediate risk in this situation.
Correct Answer is D
Explanation
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.
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