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
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.
Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
Correct Answer is B
Explanation
Bulimia nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise. Binge eating refers to the consumption of an abnormally large amount of food within a short period, accompanied by a feeling of loss of control overeating. After bingeing, individuals with bulimia nervosa feel guilty, ashamed, and anxious about their behavior, and try to compensate by purging.
Options a, c, and d are incorrect as they do not accurately describe the characteristic features of bulimia nervosa.
Avoiding social gatherings and family meals is a characteristic of social anxiety disorder, not bulimia nervosa. Restricting caloric intake all the time is a characteristic of anorexia nervosa, a different type of eating disorder. Following a strict diet and exercise program is not necessarily a characteristic of bulimia nervosa, although some individuals with bulimia nervosa may engage in excessive exercise as a compensatory behavior.
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