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 A
Explanation
This response acknowledges the client's interest in complementary therapies and opens up a conversation about the different types available. It also allows the nurse to provide education and information about the potential benefits and risks of complementary therapies and how they may interact with the planned treatment.
Correct Answer is D
Explanation
This comment indicates the possibility of obsessive-compulsive disorder (OCD) because it describes a repetitive behavior that may be a compulsion. Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. In this case, the individual’s compulsion may be to repeatedly check the location of their car keys in order to reduce anxiety or distress.

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