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 C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

A. Explain that these beliefs are related to her illness. B. Explain that distrust is related to feeling anxious. C. Initiate short, frequent contacts with the client. D. Offer to keep the belongings at the nurse's desk.

Correct Answer is C

Explanation

(A) Explain that these beliefs are related to her illness:While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious:This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client:This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk:This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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