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

This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.

A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.

B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.

C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.

A. "ECT is an effective treatment for personality disorders." B. "It is a myth that clients experience seizures during ECT." C. "Informed consent should be obtained prior to ECT." D. "should monitor the client closely for hypotension following ECT."

Correct Answer is C

Explanation

Obtaining informed consent is a crucial step before administering electroconvulsive therapy (ECT). Informed consent ensures that the client is fully informed about the procedure, its potential risks and benefits, and any alternative treatments available. It allows the client to make an autonomous decision regarding their treatment.

The other responses are not accurate:

A- "ECT is an effective treatment for personality disorders." While ECT may be used in certain cases of severe mental illness, it is not primarily indicated for personality disorders.

B- "It is a myth that clients experience seizures during ECT." Seizures are a common and expected effect of ECT. ECT involves the induction of controlled seizures under anesthesia.

D- "Should monitor the client closely for hypotension following ECT." While monitoring the client for various physiological changes is important, hypotension is not a primary concern following ECT. The nurse would typically monitor for potential adverse effects such as confusion, memory loss, headache, and muscle soreness.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse notices that a client who has moderate anxiety is pacing the hall and mumbling As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

Correct Answer is C

Explanation

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