Psychosocial Integrity Practice Question
Question
The nurse is caring for a client with major depression and is focused on anxiety scenario 6. Which nursing action is most appropriate?
Answer choices
- A. Delay assessment until the next scheduled round if the client is not calling for help.
- B. Delegate the clinical assessment and nursing judgment to assistive personnel.
- C. Document the concern without notifying the appropriate provider or care team member when escalation is needed.
- D. Remain calm, reduce stimuli, and help the client use grounding or breathing strategies.
Correct Answer
D. Remain calm, reduce stimuli, and help the client use grounding or breathing strategies.
Explanation
The priority action for anxiety is to remain calm, reduce stimuli, and help the client use grounding or breathing strategies. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.
Question details
- Difficulty: hard
- Domain: Psychosocial Integrity
- Objective: anxiety