The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Participates in individual and group therapy.

Demonstrates effective ways to cope with anxiety.

Takes all antianxiety medications as prescribed.

Learns methods of relaxation to reduce anxiety.

Answer and Explanation

The Correct Answer is B

A.   Participating in individual and group therapy is important for overall mental health, but the immediate focus is on addressing the self-harming behavior.
B.   Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
C. Taking all antianxiety medications as prescribed is important but may not directly address the client's self-harming behavior.
D.   Learning methods of relaxation is valuable, but the most immediate concern is preventing self-harm. The client should demonstrate effective ways to cope with anxiety to reduce the risk of self-injury.

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Correct Answer is D

Explanation

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

A. Inquire about the client’s support system. B. Ask the client to repeat his comment. C. Stop the client from leaving the ED. D. Record the statement in the client’s chart.

Correct Answer is C

Explanation

A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

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The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?

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