A 30-year-old woman visits the mental health clinic reporting high levels of anxiety following a traumatic event. Which of the following actions should the nurse prioritize in this scenario? (Select all that apply)
Refer to a psychiatrist for medication management
Encourage participation in group therapy
Conduct a comprehensive mental health assessment
Teach anxiety coping mechanisms
Begin cognitive behavioral therapy immediately
Correct Answer : C,D
Choice A reason: Referring to a psychiatrist for medication may be premature without a full assessment. Anxiety post-trauma can stem from PTSD or acute stress disorder, requiring a detailed evaluation to identify causes. Medications like SSRIs may help, but initiating them without understanding the client’s psychological state risks inappropriate treatment, potentially exacerbating symptoms or delaying effective care.
Choice B reason: Group therapy offers social support but may not be the priority immediately post-trauma. Trauma can heighten anxiety in group settings, potentially overwhelming the client. Scientifically, individualized assessment and coping strategies are needed first to stabilize the client’s mental state, as group dynamics may trigger stress responses or hinder early recovery efforts.
Choice C reason: A comprehensive mental health assessment is critical to identify the root causes of anxiety, such as PTSD or acute stress disorder. It evaluates cognitive, emotional, and behavioral symptoms, guiding targeted interventions. Scientifically, this ensures accurate diagnosis, preventing missteps in treatment and addressing trauma-related neurobiological changes, like heightened amygdala activity, for effective care planning.
Choice D reason: Teaching anxiety coping mechanisms, like deep breathing or mindfulness, empowers the client to manage symptoms. These techniques reduce physiological arousal, such as elevated heart rate, by activating the parasympathetic nervous system. Scientifically, they mitigate acute stress responses, promoting emotional regulation and stabilizing the client’s mental health post-trauma, enhancing long-term recovery.
Choice E reason: Beginning cognitive behavioral therapy immediately may be premature without a full assessment. CBT is effective for trauma-related disorders but requires a tailored approach based on the client’s specific symptoms. Starting without understanding the client’s psychological state risks ineffective therapy, as unaddressed acute symptoms may interfere with cognitive processing and therapeutic engagement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1 is: 20 mg ÷ 10 mg
Step 2 is: (20 ÷ 10) = 2
Final answer = 2 tablets
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Monitoring vital signs tracks withdrawal complications, like tachycardia, in alcohol use disorder. Scientifically, withdrawal causes autonomic arousal and glutamate hyperactivity, risking seizures. Regular monitoring ensures early detection of neurobiological instability, guiding interventions to stabilize physiological responses and ensure patient safety during detoxification.
Choice B reason: Fall precautions prevent injuries during withdrawal, as confusion increases risk. Scientifically, alcohol withdrawal disrupts GABA and glutamate balance, causing disorientation. Implementing precautions addresses motor and cognitive impairments, ensuring safety by mitigating neurobiological instability’s impact on physical coordination during acute detoxification phases.
Choice C reason: Hydration and electrolyte support correct imbalances from alcohol withdrawal. Dehydration and hypokalemia risk seizures due to glutamate hyperactivity. Scientifically, restoring electrolytes stabilizes neural function, preventing complications like delirium tremens, supporting physiological recovery and ensuring safety during alcohol detoxification.
Choice D reason: A mental status exam assesses withdrawal severity, like delirium or hallucinations. Scientifically, it evaluates GABA and glutamate imbalances, guiding interventions. This identifies cognitive and psychological impairments, ensuring tailored care to stabilize neurobiological responses and support recovery from alcohol use disorder’s acute effects.
Choice E reason: Benzodiazepines manage withdrawal by enhancing GABA activity, reducing neural excitability. Scientifically, they prevent seizures and delirium tremens by countering glutamate-driven hyperactivity. Administering prescribed doses ensures safety, stabilizing neurobiological responses and supporting recovery during acute alcohol withdrawal phases effectively.
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