A client in the psychiatric unit is experiencing severe anxiety—they are trembling, pacing, and saying, "I can’t think straight. I feel like something terrible is going to happen." Which of the following is the most therapeutic response by the nurse?
"You need to stop thinking this way. Nothing bad is going to happen."
"Let’s sit together here quietly. I’ll stay with you until you feel more in control."
"Try to calm down. You're safe here, so there’s nothing to worry about."
"Why are you so anxious? Can you tell me what triggered this feeling?"
The Correct Answer is B
Choice A reason: Telling the patient to stop thinking a certain way invalidates their feelings and is not therapeutic.
Choice B reason: Offering presence and calm support provides safety and helps reduce anxiety. It is the most therapeutic intervention for severe anxiety.
Choice C reason: Telling the patient not to worry may feel dismissive, and in severe anxiety the patient may not be able to process reassurance.
Choice D reason: Asking "why" is not effective when the patient is overwhelmed by severe anxiety, as they cannot engage in rational discussion at that moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: SSRIs are antidepressants used to treat depression and anxiety disorders. They do not address extrapyramidal side effects like acute dystonia, so they would not be useful in this case.
Choice B reason: Beta-blockers are primarily used for cardiovascular conditions and akathisia (a sense of restlessness), but they are not the treatment of choice for acute dystonia.
Choice C reason: Diphenhydramine, an antihistamine with strong anticholinergic properties, is effective in treating acute dystonia by restoring the balance between dopamine and acetylcholine in the basal ganglia. This makes it the correct choice for managing the client’s symptoms.
Choice D reason: Benzodiazepines may help with agitation or anxiety, but they are not first-line treatment for acute dystonic reactions caused by antipsychotic medications.
Correct Answer is C
Explanation
Choice A reason: When anxiety is severe, the client cannot focus or process complex discussions. Asking them to explore worries may overwhelm them further.
Choice B reason: Providing extensive information is inappropriate in crisis moments because the client’s concentration and comprehension are impaired.
Choice C reason: Clear, calm, and brief communication helps reduce overstimulation, provides structure, and reassures the client during high anxiety. This is the most therapeutic choice.
Choice D reason: Rapid statements can escalate the client’s sense of being overwhelmed, increasing anxiety rather than calming it.
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