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.

Answer and Explanation

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.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Monitoring vital signs throughout the day is essential for a client experiencing mania, but it is not a specific intervention related to managing the manic state. Mania is associated with high energy levels and hyperactivity, which can affect vital signs. However, this intervention does not directly address the core symptoms of mania.

Choice B rationale:

Maintaining an environment with low stimuli is crucial for managing a client experiencing mania. Manic individuals are often highly sensitive to external stimuli, and a low-stimulation environment helps reduce agitation and potential exacerbation of manic behaviors.

Choice C rationale:

Discouraging the client from taking a nap during the day is not a suitable intervention for managing mania. Sleep disturbances are common during manic episodes, and attempting to restrict daytime naps might increase restlessness and agitation.

Choice D rationale:

Weighing the client every 3 to 4 days is not a specific intervention for managing mania. Weight monitoring might be relevant in certain contexts, such as if the client's medication regimen is associated with weight changes, but it does not directly address the manifestations of mania.

Choice E rationale:

Offering nutritional foods to the client every 2 hours is an important intervention for managing mania. Manic individuals often engage in impulsive behaviors, including neglecting self-care such as eating. Providing regular and nutritious meals helps stabilize blood sugar levels and supports the body's energy demands during this hyperactive phase.

A. "Tell me what is concerning you.” B. "Crying helps us let things out and we feel better.” C. "Your husband is making really good progress.” D. "Did your husband say something to upset you?”

Correct Answer is A

Explanation

Choice A rationale:

The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.

Choice B rationale:

While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.

Choice C rationale:

Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.

Choice D rationale:

Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.

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A nurse is caring for a client who requires crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["B","E"]

Explanation

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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