A nurse is caring for a who requires a crisis intervention for acute anxiety. Which of the following actions is the highest priority?
Identify the clients’ coping skills.
Determine the cause of the client's anxiety.
Ensuring that the client feels safe.
Protecting the client from injury
The Correct Answer is D
During a crisis, the client may be at risk of harming themselves or others. The nurse should take steps to ensure the safety of the client and those around them. Once the immediate safety concerns have been addressed, the nurse can then focus on identifying the cause of the client’s anxiety and helping them develop coping skills.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with obsessive-compulsive disorder (OCD), it is important for the nurse to understand that the client’s compulsive behaviors are a way for them to manage their anxiety and distress. Rather than trying to confront or eliminate these behaviors, the nurse should work with the client to develop a schedule that allows time for their rituals while also incorporating other activities and treatments.
Option a. Confront the client about the senseless nature of repetitive behaviors is not a helpful intervention because it may increase the client’s anxiety and distress.
Option b. Isolate the client for a period of time is not a helpful intervention because it does not address the underlying causes of the client’s compulsive behaviors.
Option d. Set very strict limits on the behaviors so that the client can conform to the unit rules and schedules is not a helpful intervention because it may increase the client’s anxiety and distress and may interfere with their ability to participate in treatment.
Correct Answer is A
Explanation
According to Erikson's Stages of Psychosocial Development, the first stage is Trust vs. Mistrust, which occurs during the first 18 months of life. During this stage, infants learn to trust their caregivers and develop a sense of security and comfort in their environment. This is accomplished through consistent and responsive caregiving, including meeting the infant's physical and emotional needs.
Therefore, it is crucial for the nurse to understand the importance of building trust and significant early attachments during the first 18 months of life to promote healthy psychosocial development in pediatric clients.
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