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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Fasting blood glucose of 120 mg/dL is slightly elevated but does not contraindicate the use of chlorpromazine. This medication is primarily contraindicated in conditions that affect the central nervous system, cardiovascular system, or blood cell counts. Elevated blood glucose levels should be monitored, but they do not pose an immediate risk when starting chlorpromazine.
Choice B reason:
Hypertension is a condition that requires careful monitoring when a patient is on chlorpromazine, but it is not an absolute contraindication. Chlorpromazine can cause orthostatic hypotension, so blood pressure should be monitored regularly. However, hypertension alone does not prevent the use of this medication.
Choice C reason:
Asthma is not a contraindication for chlorpromazine. While respiratory conditions should be monitored, chlorpromazine does not have a direct adverse effect on asthma. The primary concerns with chlorpromazine involve its effects on the central nervous system and blood cell counts.
Choice D reason:
A WBC count of 3,300/mm³ indicates leukopenia, which is a significant contraindication for chlorpromazine. This medication can cause agranulocytosis, a severe reduction in white blood cells, making patients more susceptible to infections. Therefore, a low WBC count is a critical factor in deciding against the use of chlorpromazine.
Correct Answer is D
Explanation
Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.
Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.
Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.
Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.
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