A client in the emergency department following a motor vehicle crash is pacing, clenching their fists, and shouting. "I can't think! I don't know what to do!" The nurse observes that the client is unable to follow simple instructions, appears disoriented, and is hyperventilating. Which of the following nursing interventions is most appropriate for the client's current level of anxiety?
Use open-ended questions to encourage the client to express their feelings.
Encourage the client to identify and explore the source of their anxiety.
Provide concise, direct instructions in a calm, firm voice.
Offer educational materials about coping mechanisms for stress
The Correct Answer is C
Rationale:
A. Open-ended questions are more effective when anxiety is mild to moderate, not when the client is in a panic state and unable to process information.
B. Exploring anxiety triggers requires a higher level of cognitive function, which is impaired in severe or panic-level anxiety.
C. The client is displaying signs of panic-level anxiety (disorientation, inability to follow instructions, hyperventilation). In this state, the nurse should use short, clear, and direct instructions delivered in a calm, firm tone to promote safety and grounding.
D. Educational materials are not helpful during panic; the client is not in a state to absorb new information.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Open-ended questions are more effective when anxiety is mild to moderate, not when the client is in a panic state and unable to process information.
B. Exploring anxiety triggers requires a higher level of cognitive function, which is impaired in severe or panic-level anxiety.
C. The client is displaying signs of panic-level anxiety (disorientation, inability to follow instructions, hyperventilation). In this state, the nurse should use short, clear, and direct instructions delivered in a calm, firm tone to promote safety and grounding.
D. Educational materials are not helpful during panic; the client is not in a state to absorb new information.
Correct Answer is A
Explanation
Rationale:
A. A delusion is a fixed, false belief that is not based in reality and is resistant to logic or contrary evidence. In this case, the client is demonstrating a paranoid delusion involving control and surveillance.
B. Thought blocking is a sudden interruption in speech or thought, often seen in schizophrenia, but not characterized by false beliefs.
C. Word salad is incoherent, disorganized speech with no logical connection between words—unlike this client's coherent but delusional content.
D. Flight of ideas is a rapid shift from one topic to another, often seen in mania, not fixed false beliefs.
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