A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Put the client in a quiet room

Teach the client deep breathing

Remain with the client

Encourage the client to talk about their feelings and concerns

Answer and Explanation

The Correct Answer is C

Choice A reason:
Putting the client in a quiet room can help reduce external stimuli and may be beneficial in managing anxiety. However, it does not address the immediate need for support and reassurance. The presence of a nurse can provide a sense of safety and help the client feel more secure during a highly anxious state.
Choice B reason:
Teaching the client deep breathing techniques is an effective strategy for managing anxiety. However, in the immediate aftermath of a traumatic event, the client may not be able to focus on learning new techniques. Providing immediate support and reassurance is more critical at this stage.
Choice C reason:
Remaining with the client is the most appropriate immediate intervention. The nurse’s presence can provide comfort, reassurance, and a sense of safety, which are crucial in managing acute anxiety. This approach helps to stabilize the client and allows for further assessment and intervention once the client is calmer.
Choice D reason:
Encouraging the client to talk about their feelings and concerns is an important part of anxiety management, but it may not be the best immediate intervention in a severe state of anxiety. Initially, the client may need more direct support and reassurance before they are able to articulate their feelings effectively. Once the client is calmer, discussing their feelings can be beneficial.

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Correct Answer is A

Explanation

Choice A reason:
Sitting at the client’s eye level conveys respect and attentiveness. It helps create a sense of equality and openness, making the client feel heard and valued. This positive body language fosters a therapeutic relationship and encourages effective communication.

Choice B reason:
Crossing the arms over the chest can be perceived as defensive or closed-off body language. It may create a barrier between the nurse and the client, hindering open communication and making the client feel unwelcome or judged.

Choice C reason:
Sitting erect with the back against the chair can convey attentiveness and professionalism, but it may also come across as rigid or formal. While it is important to maintain good posture, it is equally important to appear approachable and relaxed.

Choice D reason:
Keeping the feet flat on the floor with the legs crossed can be seen as casual or disengaged body language. It may not convey the same level of attentiveness and respect as sitting at the client’s eye level. Positive body language should make the client feel comfortable and respected.

A. Neuroleptic malignant syndrome B. Akathisia C. Tardive dyskinesia D. Impaired ability to regulate body temperature

Correct Answer is B

Explanation

Choice A reason:
Neuroleptic malignant syndrome (NMS) is a rare but serious side effect of antipsychotic medications. It is characterized by symptoms such as high fever, muscle rigidity, altered mental status, and autonomic dysfunction. The client’s description of needing to move around does not align with the symptoms of NMS.
Choice B reason:
Akathisia is a common side effect of first-generation antipsychotic medications. It is characterized by a feeling of inner restlessness and an urgent need to move. The client’s behavior of pacing and the statement “I just need to move around” are indicative of akathisia.
Choice C reason:
Tardive dyskinesia is a long-term side effect of antipsychotic medications, characterized by involuntary, repetitive movements, particularly of the face and tongue. The client’s symptoms of needing to move around do not match the typical presentation of tardive dyskinesia.
Choice D reason:
Impaired ability to regulate body temperature can occur with antipsychotic medications, but it is not characterized by the need to move around. The client’s symptoms are more consistent with akathisia rather than issues with thermoregulation.

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A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When communicating with a client, which would a nurse use to convey positive body language?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nursing instructor is describing the impact of technology and electronic health records on psychiatric-mental health care. What would the instructor identify as a major challenge associated with technology?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?