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.

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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.

A. Administer a PRN sedative. B. Avoid recognizing the behavior. C. Escort the client to a private area. D. Isolate the client from other clients.

Correct Answer is C

Explanation

Choice A reason: Administering a PRN sedative is inappropriate for echolalia, a non-emergent symptom of schizophrenia. Sedation does not address the behavior and may cause oversedation. Escorting to a private area reduces disruption without medication, aligning with least restrictive interventions, making this incorrect.

Choice B reason: Avoiding recognition of echolalia may ignore the client’s needs and fail to address unit disruption. Escorting to a private area de-escalates the situation while maintaining engagement, offering a therapeutic response. Ignoring the behavior is less effective, making this incorrect for managing echolalia.

Choice C reason: Escorting the client to a private area minimizes disruption to others while providing a calm environment to address echolalia. This intervention reduces stimuli and supports the client therapeutically, aligning with psychiatric nursing principles for managing schizophrenia symptoms, making it the best choice for this scenario.

Choice D reason: Isolating the client is overly restrictive and may exacerbate schizophrenia symptoms like paranoia. Escorting to a private area is less isolating, maintaining therapeutic engagement while addressing unit dynamics. Isolation is not patient-centered, making this incorrect compared to a supportive, de-escalating intervention.

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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 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

A client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. Which intervention is best for the nurse to implement?

Correct Answer is C

Explanation

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