A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Instruct the client to remember past coping mechanisms.

Provide a diverting activity.

Encourage verbalization of feelings.

Remain with the client.

Answer and Explanation

The Correct Answer is D

By remaining with the client, the nurse provides a sense of support and security. This presence can help alleviate the client's anxiety and provide reassurance. It also ensures that the nurse is available to assess the client's condition, offer therapeutic communication, and intervene if the anxiety escalates or the client becomes overwhelmed.

While the other options are also beneficial interventions for managing anxiety, they are not the priority in this situation. Instructing the client to remember past coping mechanisms (Option A) can be helpful, but the immediate presence of the nurse is more important to provide immediate support.

Providing a diverting activity (Option B) can be beneficial to distract the client from their anxiety, but it does not address the underlying anxiety or provide direct support.

Encouraging verbalization of feelings (Option C) is important for therapeutic communication, but it may not be the initial priority when the client is experiencing acute anxiety.

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Correct Answer is D

Explanation

Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.

A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.

B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.

C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.

A. "You have given signed consent for the treatments after they were explained to you." B. "You can refuse them, but the provider believes they are necessary." C. "You will feel better after the course of treatments." D. "You have the right to refuse even though the consent form has been signed."

Correct Answer is D

Explanation

Informed consent is an essential ethical principle in healthcare, including mental health treatment. Even if the client has previously signed a consent form for electroconvulsive therapy (ECT), they have the right to change their mind and refuse the treatment at anytime. Respecting the client's autonomy and their right to make decisions about their own healthcare is crucial.

The nurse's response should support the client's right to refuse the treatment, rather than attempting to persuade or convince them otherwise. It is important to provide information, answer questions, and discuss the client's concerns or reasons for refusing the treatment. The client's decision should be respected and further discussions can be held with the healthcare provider to explore alternative treatment options or address any concerns the client may have.

A- "You have given signed consent for the treatments after they were explained to you." - This response does not acknowledge the client's right to refuse the treatment. Even if the client previously provided consent, they still have the right to change their mind and refuse the treatment. Informed consent is an ongoing process, and the client's autonomy should be respected throughout their care.

B- "You can refuse them, but the provider believes they are necessary." - While it may be true that the healthcare provider believes ECT is necessary, this response does not fully acknowledge the client's autonomy. It is important to emphasize the client's right to make decisions about their own healthcare, independent of the provider's opinion. The decision to refuse or accept the treatment should ultimately be made by the client.

C- "You will feel better after the course of treatments." - This response does not address the client's concerns or their right to refuse the treatment. It is essential to respect the client's autonomy and their ability to make decisions about their own care, even if their decision may not align with the potential benefits of the treatment. The nurse should focus on providing information, addressing the client's concerns, and supporting their decision-making process.

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A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

Nursing Test Bank

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Explanation

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