A client diagnosed with an Anxiety Disorder tells a nurse that being in crowds creates thoughts of losing control and the need to suddenly leave. What should the nurse recommend as an effective, non-pharmacological therapy for managing the client’s symptoms of anxiety?

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

Choice A Reason:

Aggressive and angry.

Aggressive and angry behavior is not indicative of apathy. Apathy is characterized by a lack of interest, enthusiasm, or concern. Aggression and anger are more likely to be associated with other symptoms of schizophrenia, such as paranoia or frustration, rather than apathy.

Choice B Reason:

Concerned over recent events.

Being concerned over recent events shows an active engagement with one’s environment and emotions. This is the opposite of apathy, which involves a lack of interest or concern. Therefore, this behavior does not align with the definition of apathy.

Choice C Reason:

Indifferent to their surroundings.

This is the correct response. Indifference to one’s surroundings is a clear sign of apathy. In schizophrenia, apathy is a common negative symptom and involves a diminished ability to initiate and sustain activities, including social interactions. This lack of interest or motivation is a key feature of apathy.

Choice D Reason:

Supportive in group.

Being supportive in a group setting indicates active participation and concern for others, which is not consistent with apathy. Apathy would manifest as a lack of engagement or interest in group activities and interactions.