The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?
Reinforce personal strengths observed in the client.
Suggest ways to problem solve adapting to the new home.
Help the client know they will not always feel this way.
Inquire respectfully about the events of the departure.
The Correct Answer is D
A. Reinforcing personal strengths is a positive intervention, but in this context, understanding the underlying cause of anxiety should take precedence.
B. Suggesting ways to problem-solve adapting to the new home is a valuable intervention, but assessing the specific stressors or traumas the client may have experienced is more immediate.
C. Helping the client know they will not always feel this way is supportive, but understanding the context and potential triggers for anxiety is the first step.
D. Inquiring respectfully about the events of the departure is the most important initial intervention to gather information about potential traumatic experiences that may be contributing to the client's anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Disulfiram should be taken each morning, and it is recommended to start it 48 hours after the last drink of alcohol to prevent a severe reaction. This helps establish a clear association between the medication and alcohol avoidance.
B. While taking disulfiram with water is generally advisable, the crucial aspect is the timing and the initial 48-hour abstinence period.
C. Taking the medication at bedtime or limiting alcohol to one ounce daily does not address the specific timing requirement for disulfiram initiation.
D. Beginning the medication immediately and taking it daily, regardless of alcohol consumption, may not establish the necessary 48-hour alcohol-free period before starting disulfiram.
Correct Answer is D
Explanation
A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.
B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.
C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.
D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.
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