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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Instructing the client to reduce the volume of his voice may not be effective during a manic episode and could escalate the situation.
B. Accompanying the client to a quiet area of the unit provides a more supportive and calming environment, allowing the client to deescalate.
C. Encouraging the client to attend a support group is a positive intervention but may not be immediately effective during an agitated state.
D. Administering a PRN sedative by injection may be considered, but less restrictive interventions should be attempted first to promote a therapeutic environment.

A. Disturbed sensory perception. B. Compromised family coping. C. Ineffective sexual patterns D. Impaired environmental interpretation.

Correct Answer is A

Explanation

A. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

Correct Answer is B

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?

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?

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 leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?