Which of the following is a priority when caring for a highly anxious patient?
Implement strict limit-setting to control behavior.
Increase environmental stimuli to distract the patient.
Provide support and a therapeutic milieu.
Provide more freedom to promote self-expression.
The Correct Answer is C
Choice A reason: While limit-setting is important, it should not be overly strict as it can increase anxiety in patients who are already highly anxious.
Choice B reason: Increasing environmental stimuli may overwhelm a highly anxious patient rather than help them.
Choice C reason: Providing support and a therapeutic milieu offers a safe and structured environment, which can help reduce anxiety and promote healing.
Choice D reason: More freedom can be beneficial, but it must be balanced with the need for a supportive and structured environment for a highly anxious patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Mood and affect are essential components of the mental health status examination, reflecting the patient's emotional state and its expression.
Choice B reason: Memory is a cognitive function that is assessed during the mental health status examination to determine if there are any deficits.
Choice C reason: Judgment is evaluated to understand the patient's decision-making abilities, which can be affected in various mental health conditions.
Choice D reason: "Mood and tone" is not a standard component of the mental health status examination. The term "tone" typically refers to the quality of voice or speech.
Choice E reason: Level of awareness and orientation are assessed to determine the patient's consciousness level and their awareness of time, place, and person.
Correct Answer is D
Explanation
Choice A: "I’m sorry if I upset you. I just wanted to make sure you’re aware of the day’s schedule."
This response may seem empathetic, but it could potentially reinforce the client's aggressive behavior. The nurse is apologizing, which might give the impression that the client's rude behavior is acceptable¹.
Choice B: "Well, if you can read it yourself, then why don’t you?"
This response is confrontational and could escalate the situation. It's important for the nurse to maintain a neutral and respectful manner.
Choice C: "You don’t have to be so rude. I’m just doing my job."
This response is defensive and could provoke further aggression from the client. It's not recommended to respond defensively to clients with borderline personality disorder¹.
Choice D: "I didn’t mean to offend you. I’ll leave the schedule here for you to review."
This is the most appropriate response. The nurse acknowledges the client's feelings without reinforcing the aggressive behavior. The nurse also respects the client's autonomy by leaving the schedule for the client to review¹.
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