A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

Develop a flexible crisis intervention plan.

Identify the cause of the anxiety.

Validate the client’s feelings.

Establish rapport with the client.

Avoid eye contact to prevent escalation of anxiety.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Developing a flexible crisis intervention plan is essential in managing a client’s anxiety crisis. Flexibility allows the nurse to adapt the plan to the client’s changing needs and circumstances, ensuring that the interventions remain effective and appropriate.

Choice B reason:

Identifying the cause of the anxiety is crucial for effective intervention. Understanding the underlying factors contributing to the client’s anxiety helps the nurse address the root of the problem and develop targeted strategies to alleviate the client’s distress.

Choice C reason:

Validating the client’s feelings is an important therapeutic technique. It helps the client feel understood and supported, which can reduce anxiety and build trust between the client and the nurse. Validation acknowledges the client’s emotions without judgment.

Choice D reason:

Establishing rapport with the client is fundamental in any therapeutic relationship. Building rapport fosters trust and open communication, which are essential for effective crisis intervention. A strong therapeutic relationship can help the client feel more secure and supported.

Choice E reason:

Avoiding eye contact is not recommended as it can be perceived as dismissive or disinterested. Maintaining appropriate eye contact shows that the nurse is engaged and attentive, which can help reassure the client and reduce anxiety. It is important to balance eye contact to avoid making the client feel uncomfortable.

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Correct Answer is B

Explanation

Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.

Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.

Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.

Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.

A. Cognitive Therapy B. Milieu Therapy C. Family Therapy D. Electroconvulsive Therapy

Correct Answer is B

Explanation

Choice A reason:
Cognitive therapy focuses on changing negative thought patterns and behaviors through structured sessions with a therapist. While it is an effective treatment for many mental health conditions, it does not involve the structured daily routines described in the scenario. Cognitive therapy is typically conducted in individual or group sessions rather than through the daily activities of an inpatient unit.

Choice B reason:
Milieu therapy involves creating a therapeutic environment that supports the client’s recovery through structured daily routines and interactions with staff and peers. The emphasis on getting up at a certain time, attending meals, and taking medications on schedule is characteristic of milieu therapy. This approach helps clients develop healthy habits, social skills, and a sense of responsibility.

Choice C reason:
Family therapy involves working with the client and their family members to improve communication, resolve conflicts, and support the client’s recovery. While family therapy is an important component of comprehensive mental health care, it does not involve the structured daily routines described in the scenario. Family therapy sessions are typically scheduled separately from the client’s daily activities.

Choice D reason:
Electroconvulsive therapy (ECT) is a medical treatment that involves inducing controlled seizures to alleviate severe psychiatric symptoms. ECT is typically administered in a hospital setting under anesthesia and is not related to the structured daily routines described in the scenario. It is used for specific conditions, such as severe depression or treatment-resistant schizophrenia, and is not a form of therapy that involves daily activities.

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A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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