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 D

Explanation

Choice A reason:

A teenager who refuses to participate in the planned therapy does not necessarily meet the criteria for involuntary commitment. Refusal to participate in therapy can be addressed through other means, such as motivational interviewing or adjusting the treatment plan to better engage the client.

Choice B reason:

A 24-year-old client who refuses to take the prescribed medication also does not automatically qualify for involuntary commitment. Non-compliance with medication can be managed through education, support, and exploring the reasons behind the refusal. Involuntary commitment is typically reserved for situations where the client poses a danger to themselves or others.

Choice C reason:

A 45-year-old client who is homeless and has been diagnosed with a mental disorder may need support and resources, but homelessness and a mental health diagnosis alone do not justify involuntary commitment. The focus should be on providing housing and mental health services rather than involuntary hospitalization.

Choice D reason:

An elderly client who is confused, screaming obscenities in the street, and disturbing neighbors is exhibiting behavior that may pose a risk to themselves or others. This situation suggests a level of acute distress or potential danger that could warrant involuntary commitment to ensure the client’s safety and provide necessary treatment.

A. Place the client in seclusion if visual hallucinations are present. B. Limit the number of questions asked during assessments. C. Use frequent touch to provide client support. D. Directly tell the client that delusions are not real.

Correct Answer is B

Explanation

Choice A reason:
Placing the client in seclusion if visual hallucinations are present is not an appropriate first-line intervention. Seclusion should only be used when the client poses an immediate threat to themselves or others and less restrictive measures have failed. It is important to use the least restrictive interventions to manage symptoms.

Choice B reason:
Limiting the number of questions asked during assessments can help reduce the client’s anxiety and prevent overwhelming them. Clients with schizophrenia may have difficulty processing information and may become more paranoid or distressed with too many questions. This approach helps create a more supportive and manageable environment for the client.

Choice C reason:
Using frequent touch to provide client support is not recommended for clients with paranoid delusions. Physical touch may be misinterpreted as a threat or invasion of personal space, exacerbating the client’s paranoia and anxiety. It is important to respect the client’s boundaries and use other forms of support.

Choice D reason:
Directly telling the client that delusions are not real can be confrontational and may increase the client’s distress. Instead, the nurse should acknowledge the client’s feelings and provide reassurance without directly challenging their beliefs. This approach helps maintain a therapeutic relationship and supports the client’s emotional well-being.

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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

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

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 applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?

A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?

A nurse is reviewing the medical record of a client who has a new prescription for chlorpromazine for the treatment of schizophrenia. Which of the following findings indicates a contraindication to chlorpromazine?

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?