Which action should a nurse plan for a client who has episodes of acute anxiety?
Isolate the client when there are observable physiologic symptoms of anxiety.
Ignore the client’s behavior as obvious attempts to gain attention.
Reduce all stress whenever the client seems anxious.
Assist the client to identify triggers for the episodes.
The Correct Answer is D
This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.
Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.
The nurse should stay with the client and offer reassurance and comfort.
Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.
The nurse should acknowledge the client’s feelings and provide empathy and support.
Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.
The nurse should help the client to identify healthy ways of managing stress and anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because immobilizing the wrist prevents kinking or dislodgement of the intravenous catheter and reduces the risk of complications such as infiltration, phlebitis, or infection.
Some additional information for the response are:
Choice A is wrong because placing the arm across the client’s chest may compromise venous return and increase the risk of thrombosis.
Choice B is wrong because using a wrist restraint may cause skin breakdown, nerve damage, or impaired circulation.
Choice D is wrong because instructing the client to limit use the of that arm may not be sufficient to prevent catheter movement or accidental removal.
Normal ranges for venous access depend on the type and location of the catheter, but some general values are: potassium (3 to 5 mEq/L), blood urea nitrogen (10 to 20 mg/dL), and central venous pressure (8 to 12 mmHg).
Correct Answer is C
Explanation
The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.
Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.
It is a matter of time management and prioritization.
Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.
It is a part of the nursing documentation and communication.
Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.
It is a personal injury that may be related to improper body mechanics or ergonomics.
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