NCLEX-PN

Category - Psychosocial Integrity

A client is admitted with a diagnosis of anxiety disorder. On assessment, the client demonstrates increased vital signs, slight perspiration, periodic slow pacing, difficulty concentrating, and decreased span of attention. Which of the following nursing interventions is the most appropriate?
  1. Initiation of seclusion
  2. Application of restraints
  3. Assist the client with problem solving skills
  4. Accept the signs of anxiety as natural and tolerable
Explanation
Answer: C - The client is experiencing signs and symptoms of moderate anxiety. The most appropriate action of the nurse is to assist the client with problem solving skills. Restraints are only considered if the client is at risk for self-injury or if he or she poses a threat to the safety of others. Moderate anxiety has to be addressed, as its escalation can lead to severe anxiety or panic.
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