Which action should a nurse plan for a client who has episodes of acute anxiety?

Isolate the client when there are observable physiologic symptoms of anxiety.

Ignore the client’s behavior as obvious attempts to gain attention.

Reduce all stress whenever the client seems anxious.

Assist the client to identify triggers for the episodes.

Answer and Explanation

The Correct Answer is D

This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.

Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.

The nurse should stay with the client and offer reassurance and comfort.

Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.

The nurse should acknowledge the client’s feelings and provide empathy and support.

Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.

The nurse should help the client to identify healthy ways of managing stress and anxiety.

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Correct Answer is D

Explanation

A back massage is a type of cutaneous stimulation that can help reduce pain by activating the gate control theory of pain. Cutaneous stimulation is a non-pharmacological intervention that can be delegated to unlicensed assistive personnel (UAP) or nursing assistive personnel (NAP) under the supervision of a registered nurse.

Choice A is wrong because assessing pain status requires critical thinking and clinical judgment, which are skills that only registered nurses have. Pain assessment is not a task that can be delegated to UAP/NAP.

Choice B is wrong because administering a placebo is a type of pharmacological intervention that involves giving a substance that has no therapeutic effect. Placebos are unethical and ineffective for pain management and should not be used by any health care provider.

Choice C is wrong because reviewing a pain diary involves evaluating the patient’s response to pain interventions and adjusting the plan of care accordingly. This is a complex task that requires nursing knowledge and skills and cannot be delegated to UAP/NAP.

A. “It wouldn’t have mattered what you had worn.”. B. “The current styles are an invitation to disaster.”. C. “Never mind about blame. D. That will be determined by the court.”.

Correct Answer is A

Explanation

“It wouldn’t have mattered what you had worn.” This response by a nurse is appropriate because it validates the client’s feelings and helps to reduce self-blame. It also conveys that rape is not caused by the victim’s clothing or behavior, but by the perpetrator’s violence and lack of respect.

Choice B. “The current styles are an invitation to disaster.” is wrong because it implies that the client is responsible for the rape and that she could have prevented it by dressing differently. This response is judgmental and insensitive, and may increase the client’s guilt and shame.

Choice C. “Never mind about blame.

That will be determined by the court.” is wrong because it dismisses the client’s feelings and does not address her emotional needs.

It also suggests that the nurse does not believe the client or support her. This response may make the client feel isolated and distrustful.

Choice D. “Some people don’t have very good self-control.

We have to help them all we can.” is wrong because it excuses the perpetrator’s behavior and shifts the blame to the victim.

It also implies that rape is a result of sexual desire, rather than an act of violence and domination. This response may make the client feel powerless and helpless.

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Which action should a nurse plan for a client who has episodes of acute anxiety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is attempting to use non-pharmacological treatment for pain control. Which treatment could the nurse delegate to the UAP?

Correct Answer is D

Explanation

A client in the emergency department who has been raped says repeatedly, “if only I hadn’t worn that sexy dress.” Which response by a nurse is appropriate?

Correct Answer is A

Explanation

A client is to receive one liter of normal saline intravenously over six hours. The tubing delivers 15 drops per milliliter. How many drops per minute should a nurse regulate the infusion to deliver?

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The nurse knows that documentation should record the interventions and the care given to the client. What is the rationale?

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