During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Ask the client why she is so anxious.

Administer a PRN sedative to help relieve anxiety.

Assist the client in developing alternative coping skills.

Remain calm and use a matter-of-fact approach.

Answer and Explanation

The Correct Answer is D

A) Asking the client why she is so anxious might seem like a valid approach to understand her feelings; however, at this moment, she may not be able to articulate her anxiety effectively. Instead of exploring the reasons for her anxiety right away, it's more important to provide immediate support.

B) Administering a PRN sedative can provide temporary relief for severe anxiety, but it should not be the first line of intervention during the admission process. Pharmacological intervention is important, but establishing a therapeutic relationship and using non-pharmacological approaches can be equally or more effective in the long term.

C) Assisting the client in developing alternative coping skills is a valuable intervention, but it may not be appropriate to initiate this process immediately during the admission phase when the client is experiencing acute anxiety. The client needs first to feel safe and stabilized.

D) Remaining calm and using a matter-of-fact approach is the most important intervention during the admission process. This approach helps create a safe environment and reassures the client. By modeling calmness, the nurse can help reduce the client’s anxiety levels and foster a sense of security, allowing for better engagement and assessment.

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Correct Answer is A

Explanation

A) Staying quietly with the client is the best approach in this situation. By remaining present and calm, the nurse can provide a sense of safety and support. This non-confrontational presence may help the client feel more secure and reduce her agitation over time.

B) Telling the client that she is out of control may escalate her frustration and feelings of being judged. This could worsen the situation rather than help it, as it does not offer any constructive feedback or support.

C) Ignoring the client's acting out behavior is not appropriate. Acknowledging her feelings and providing support is essential, even if her behavior is challenging. Ignoring her could lead to further escalation and feelings of isolation.

D) Distracting her by offering finger foods could be an effective strategy if the client is calm enough to engage in that activity. However, if she is currently shouting and screaming, she may not be receptive to distraction techniques. Addressing her emotional state first is more critical.

A. Describe the consequences of his behavior in concrete terms. B. Encourage the client to verbalize his feelings of anger. C. Ignore blaming behavior and praise the client's appropriate behavior. D. Explain that blaming others limits his psychological growth.

Correct Answer is A

Explanation

A) Describing the consequences of the adolescent's behavior in concrete terms is the best action. This approach helps the client understand the direct impact of his actions on himself and others. Clear and specific explanations can facilitate accountability and encourage the adolescent to reflect on how his behavior affects his relationships and environment, which is essential for behavior modification.

B) Encouraging the client to verbalize his feelings of anger may provide an outlet for his emotions, but it does not directly address the problematic behavior of blaming others. While exploring feelings is important, it should be paired with teaching responsibility and consequences for behavior.

C) Ignoring blaming behavior and praising appropriate behavior might reinforce a lack of accountability. While positive reinforcement is beneficial, it is crucial to address negative behaviors directly to facilitate change. Ignoring the blaming behavior could lead to its continuation.

D) Explaining that blaming others limits his psychological growth could be insightful, but it may not resonate with the adolescent or lead to immediate behavior change. The focus should be on concrete consequences that he can understand and relate to, which can encourage more constructive behaviors.

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During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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