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 C

Explanation

Choice A rationale:

While wanting to go home to be with loved ones can be a sign of distress, it doesn't necessarily indicate an immediate risk of suicide. Many individuals express a desire to be with family when feeling down, and this statement alone is not a definitive indicator of suicide risk.

Choice B rationale:

Engaging in social activities like playing basketball with others is generally a positive sign, as it indicates some level of interaction and engagement. This choice is less likely to indicate an immediate suicide risk.

Choice C rationale:

The client demonstrating increased impulsive behaviors is a concerning sign. Rapid and impulsive actions can potentially lead to self-harm or dangerous situations. Increased impulsivity can indicate a lack of consideration for consequences, which may elevate the risk of suicidal behaviors.

Choice D rationale:

Identifying with problems expressed by other clients is not a specific indicator of suicide risk. While it may suggest empathy and shared experiences, it doesn't directly address the immediate risk factors related to the client's bipolar disorder.

A. Instruct the client to sit down and stop pacing. B. Have a staff member escort the client to her room. C. Walk with the client at a gradually slower pace. D. Allow the client to pace alone until physically tired.

Correct Answer is C

Explanation

The correct answer is choice C. Walk with the client at a gradually slower pace.

Choice A rationale:

Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.

Choice B rationale:

Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.

Choice C rationale:

Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.

Choice D rationale:

Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.

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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 in an acute care mental health facility is assessing a client who has bipolar disorder. The nurse recognizes that which of the following findings indicates the client is at risk for suicide?

Correct Answer is C

Explanation

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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