A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Progressively expose the client to larger crowds.

Encourage substitution of positive thoughts for negative ones.

Establish trust by providing a calm, safe environment.

Encourage deep breathing when anxiety escalates in a crowd.

Answer and Explanation

The Correct Answer is C

Choice A reason: Progressive exposure to crowds is part of desensitization but is not the highest priority initially. Without trust and a safe environment, exposure may overwhelm the client, hindering therapy. Establishing trust ensures the client feels secure to engage in desensitization, making this less immediate than building rapport.

Choice B reason: Substituting positive thoughts helps manage anxiety but is secondary to establishing trust. Without a safe, trusting environment, cognitive strategies may be ineffective for a client with agoraphobia. Trust facilitates engagement in therapy, making this intervention less critical than creating a calm, supportive setting initially.

Choice C reason: Establishing trust by providing a calm, safe environment is the highest priority, as it builds the foundation for desensitization therapy. For agoraphobia, feeling secure enables the client to engage in exposure and cope with anxiety, aligning with psychiatric nursing principles for anxiety disorder management.

Choice D reason: Deep breathing is a useful coping strategy for anxiety but is less critical than establishing trust. Without a safe environment, the client may not feel secure enough to practice techniques during crowd exposure. Trust is foundational for therapeutic success, making this intervention secondary.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Identifying effective coping strategies is critical for an adolescent with suicidal ideation triggered by anger, as it addresses the root cause of the suicide attempt. This goal promotes emotional regulation and prevents future self-harm, aligning with psychiatric nursing priorities for suicide risk management.

Choice B reason: Attending group sessions supports socialization but does not directly address the client’s suicidal behavior or emotional triggers. Coping strategies are more critical to prevent recurrence of self-harm, making this goal less important than learning to manage feelings effectively in this context.

Choice C reason: Positive staff interaction fosters therapeutic alliance but does not target the client’s suicidal ideation or anger management. Developing coping skills is more critical to address the underlying emotional dysregulation, making this goal secondary to learning effective strategies for handling intense feelings.

Choice D reason: Expressing anger towards family may escalate conflict without resolving the client’s suicidal behavior. Teaching coping strategies is more important to manage emotions safely, preventing further self-harm. This goal is less therapeutic and potentially harmful, making it incorrect for priority care planning.

A. Determine if the mother has other children who do not have developmental disabilities. B. Encourage the mother to write thoughts and feelings in a journal. C. Ask the mother if she has ever thought about harming herself or her child. D. Reassure the mother that her child will achieve some growth and development milestones.

Correct Answer is C

Explanation

Choice A reason: Asking about other children shifts focus from the mother’s expressed depression and does not address her emotional distress or safety. Assessing for suicidal or harmful thoughts is critical given her depression, making this less urgent and incorrect for responding to her immediate emotional state.

Choice B reason: Journaling may help process emotions but does not address the immediate risk of depression-related self-harm or harm to the child. Assessing for suicidal ideation is the priority to ensure safety, making journaling secondary and incorrect for the nurse’s initial response to this mother.

Choice C reason: Asking about thoughts of harming herself or her child is critical, as the mother’s depression raises safety concerns. This assesses suicide or infanticide risk, prioritizing safety in a high-stress caregiving situation, aligning with psychiatric nursing principles for maternal mental health crisis intervention.

Choice D reason: Reassuring about milestones is dismissive of the mother’s grief and depression, potentially minimizing her distress. Assessing for harmful thoughts ensures safety, addressing the immediate risk of her emotional state. False reassurance is untherapeutic, making this incorrect for responding to her depression.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mental health unit nurse completes the admission assessment for a depressed adolescent client with suicidal ideation. The client reports becoming angry with a sibling, so the client took a handful of pills. Which goal is most important for the nurse to establish with this client?

Correct Answer is A

Explanation

The mother of an infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Correct Answer is C

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. While planning nursing care, which intervention has the highest priority at this time?

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client?

The nurse is assessing a client with paranoia. Which behavior can this client be expected to exhibit?

A client is receiving benztropine mesylate for drug-induced extrapyramidal syndrome (EPS). Which finding indicates that the nurse should further evaluate the client?