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 B
Explanation
The correct answer is choice B: Is an aversion therapy that produces unpleasant consequences for undesirable behavior.
Choice A rationale:
Decreases or eliminates a behavior by introducing a more adaptive behavior that is incompatible with the unacceptable behavior. Choice A refers to the technique of "differential reinforcement," where an undesirable behavior is replaced by a more appropriate behavior. This technique involves reinforcing positive behaviors while ignoring or providing minimal attention to negative behaviors. It is not the same as covert sensitization.
Choice B rationale:
Is an aversion therapy that produces unpleasant consequences for undesirable behavior. Covert sensitization is a form of aversion therapy used to eliminate unwanted behaviors by associating them with unpleasant imagery or thoughts. It's based on the principle that if a person can associate a negative response with a certain behavior, they will be less likely to engage in that behavior. This technique is used for behaviors like addiction or certain compulsive behaviors.
Choice C rationale:
An aversive stimulus or punishment during which the client is removed from the environment where the unacceptable behavior is being exhibited. Choice C refers to "time-out," a technique used to decrease undesirable behaviors by removing the individual from the environment where the behavior is occurring. This is often used with children and involves giving them a brief break from a situation to help them calm down. It's not the same as covert sensitization.
Choice D rationale:
Relies on an individual's imagination rather than medication for unpleasant symptoms. Choice D is not directly related to covert sensitization. Covert sensitization involves creating a negative association with a behavior using mental imagery. It's not about relying on imagination instead of medication.
Correct Answer is ["A","B","D"]
Explanation
The correct answer is choicea. Low self-esteem,b. Family history of addiction, andd. Personality disorders.
Choice A rationale:
Low self-esteem is considered a risk factor for addictive disorders.Individuals with low self-esteem may use substances as a coping mechanism to deal with negative feelings about themselves.
Choice B rationale:
A family history of addiction is a significant risk factor.Genetic predisposition plays a crucial role in the development of addictive behaviors.
Choice C rationale:
Asian ethnicity is not typically considered an etiological factor for addictive disorders.In fact, some studies suggest that certain genetic factors in Asian populations may reduce the risk of alcohol addiction.
Choice D rationale:
Personality disorders, such as borderline personality disorder or antisocial personality disorder, are associated with a higher risk of substance use disorders.These disorders can lead to behaviors that increase the likelihood of addiction.
Choice E rationale:
Being female is not a direct etiological factor for addictive disorders.However, gender can influence the patterns and consequences of substance use, with males generally having a higher prevalence of substance use disorders.
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