When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Request backup from the staff.

Stand in the doorway.

Provide for personal space.

Encourage the client to sit down.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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Correct Answer is C

Explanation

Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.

Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."

Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.

Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.

A. Assist the client with relaxation techniques in the group. B. Escort the client from the group to reduce stimuli. C. Provide education about ways to cope with anxiety. D. Ask the client to describe and identify the source of the feelings.

Correct Answer is A

Explanation

Choice A rationale:
Assisting the client with relaxation techniques within the group is an appropriate and immediate intervention for managing severe anxiety. This approach can help the client regulate their anxiety levels and provide a sense of support in the therapeutic environment.

Choice B rationale:
Escorting the client from the group to reduce stimuli may be considered if the client's anxiety becomes overwhelming and they cannot manage it within the group setting. However, it is generally preferable to try in-group interventions first.

Choice C rationale:
Providing education about ways to cope with anxiety is valuable, but it may not be the most effective intervention in the moment when the client is already experiencing severe anxiety. Practical techniques should be initiated first.

Choice D rationale:
Asking the client to describe and identify the source of the feelings may be a useful therapeutic technique in individual therapy sessions but may not be the best immediate intervention during a group therapy session when the focus is on managing acute anxiety.

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When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is C

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is A

Explanation

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