A client who has agoraphobia 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?

Establish trust by providing a calm, safe environment.

Encourage deep breathing when anxiety escalates in a crowd.

Progressively expose the client to larger crowds.

Encourage substitution of positive thoughts for negative ones.

Answer and Explanation

The Correct Answer is A

A.   Establishing trust by providing a calm, safe environment is crucial for clients with agoraphobia, as it lays the foundation for effective therapeutic interventions and supports the client's sense of safety and security.
B.   Encouraging deep breathing is a helpful coping strategy, but it may not be the highest priority compared to establishing trust and safety.
C.   Progressively exposing the client to larger crowds is part of desensitization therapy, but it should be done gradually and only after trust and rapport have been established.
D.   Encouraging substitution of positive thoughts for negative ones is a valuable cognitivebehavioral technique, but it may be more effective once the client feels safe and supported in the therapeutic environment.

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Correct Answer is ["B","C","D"]

Explanation

A. Restricting visitors may exacerbate feelings of isolation and may not be therapeutic for the adolescent client who is depressed.
B. Reinforcing statements regarding a will to live and realistic plans for the future can provide hope and motivation for the adolescent to engage in treatment and recovery.
C. Understanding the client's suicide plan is crucial for assessing risk and planning appropriate interventions to ensure safety.
D. Encouraging the client to discuss thoughts and feelings promotes open communication and allows the adolescent to express emotions, which can be therapeutic and supportive in managing depression.
E. While limiting excessive screen time, including video games, may be beneficial for overall well-being, it may not directly address the underlying issues contributing to the adolescent's depression and may be less relevant in the immediate plan of care.

A. "If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." B. "Even if the client will not call the police, the nurse should advise the C. "Even if the client will not call the police, the nurse should advise the police of what has happened." D. "Consent is not required to collect evidence from a person who has been sexually assaulted." E. "The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert."

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." Understanding: This statement acknowledges the importance of preserving evidence even if the client chooses not to involve the police. Collecting evidence can be crucial for future legal proceedings or for the client's own decision-making process.
-"Even if the client will not call the police, the nurse should advise the police of what has happened." No understanding: This statement suggests that the nurse should bypass the client's autonomy and directly involve the police without the client's consent. It fails to recognize the importance of respecting the client's autonomy and confidentiality.
-"The client has to consent in order for me to document his injuries in the chart." Understanding: This statement demonstrates an understanding of the importance of obtaining the client's consent before documenting any information related to their care, including injuries, in their medical chart.
-"Consent is not required to collect evidence from a person who has been sexually assaulted." No understanding: This statement is incorrect. Consent is always required, even when collecting evidence from a person who has been sexually assaulted. Failing to obtain consent could violate the individual's rights and lead to legal and ethical repercussions.
-"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert." Understanding: This statement correctly
Prepared by Brandel
identifies that sexual assault exams should ideally be performed by trained professionals, such as Sexual Assault Nurse Examiners or emergency room physicians with expertise in forensic examinations. These professionals are better equipped to handle the sensitive nature of such exams and collect evidence effectively.

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A client who has agoraphobia 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

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Which reason(s) should the nurse expect a female client to use when she is having difficulty leaving a relationship where she is a victim of intimate partner violence? Select all that apply.

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?

The nurse wants to teach the client about the long-term phase symptoms of rape-trauma syndrome. What symptoms are consistent with long-term rape trauma? Select all that apply.

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?