A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following actions should be the nurse's highest priority?
Protecting the client from injury
Identifying the client's coping skills
Ensuring that the client feels safe
Determining the cause of the client's anxiety.
The Correct Answer is A
Choice A rationale:
Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
The correct answer is choiceAandE.
Choice A rationale:
Monitoring the client’s weight daily is crucial in managing anorexia nervosa.It helps track the client’s progress and ensures that any significant weight changes are promptly addressed.
Choice B rationale:
Allowing the client to choose their meals can be counterproductive.Clients with anorexia nervosa may make choices that do not support their nutritional needs, potentially exacerbating their condition.
Choice C rationale:
Allowing the client to practice strenuous exercises is not advisable.Strenuous exercise can further deplete the client’s already low energy reserves and exacerbate malnutrition.
Choice D rationale:
Staying with the client during meals and for 2 hours after meals is incorrect.The recommended practice is to stay with the client for 30 minutes after meals to monitor for any purging behaviors.
Choice E rationale:
Providing the client with small meals frequently is beneficial. It helps in managing their nutritional intake without overwhelming them, which can be more acceptable and manageable for clients with anorexia nervosa.
Correct Answer is C
Explanation
Choice A rationale: Clients who are admitted involuntarily cannot be hospitalized for as long as the provider deems necessary. There are legal and ethical guidelines that dictate the length and conditions of involuntary hospitalization. These guidelines vary by jurisdiction, but they generally require periodic review and reevaluation of the client’s condition and the necessity of continued hospitalization.
Choice B rationale: Clients cannot be given medications against their will under normal circumstances. Informed consent is a fundamental right in healthcare, including mental health care. This means that clients have the right to be fully informed about the potential benefits, risks, and alternatives of a proposed treatment, and to make an informed decision about whether to accept or refuse the treatment. There are exceptions in emergency situations where the client poses an immediate danger to self or others, but these are governed by strict legal and ethical guidelines.
Choice C rationale: Clients who are involuntarily admitted do have the right to informed consent. This means that even if a client is admitted to a mental health facility against their will, they still have the right to be informed about their treatment and to make decisions about their care. This includes the right to be informed about the potential benefits, risks, and alternatives of proposed treatments, and the right to refuse treatment.
Choice D rationale: The laws regarding restraints are not different for clients who are admitted involuntarily. Restraints can only be used as a last resort when less restrictive interventions have failed and the client poses an immediate danger to self or others. The use of restraints is governed by strict legal and ethical guidelines, and these apply to all clients, regardless of whether they were admitted voluntarily or involuntarily.
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