A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
Identifying the client's coping skills.
Protecting the client from injury to himself.
Determining the cause of the client's anxiety.
Ensuring that the client feels safe.
The Correct Answer is B
Choice A rationale:
Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.
Choice B rationale:
Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.
Choice C rationale:
Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.
Choice D rationale:
Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.
Choice B rationale:
"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.
Choice C rationale:
"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.
Choice D rationale:
(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.
Correct Answer is B
Explanation
Choice A rationale:
Identifying the client's coping skills is an important assessment, but in the context of acute anxiety requiring crisis intervention, immediate safety takes precedence over assessment. Coping skills assessment can follow once the client is stable.
Choice B rationale:
Protecting the client from injury to himself is the highest priority in this scenario. Acute anxiety can lead to behaviors that pose a risk to the client's safety, such as self-harm or suicide. Ensuring the client's physical safety is paramount.
Choice C rationale:
Determining the cause of the client's anxiety is relevant for long-term care but not the immediate priority during crisis intervention. Immediate safety concerns must be addressed first.
Choice D rationale:
Ensuring that the client feels safe is important, but physical safety takes precedence. The client's subjective feeling of safety may not necessarily prevent them from engaging in harmful behaviors.
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