A mental health nurse is assessing a client who reports an increase in anxiety. Which of the following responses should the nurse make?
"Do you think your anxiety is worse than everyone else's?"
"It doesn't appear as though you are feeling anxious."
"Tell me what has been happening lately."
"I think you should see a therapist and a doctor tomorrow.".
The Correct Answer is C
Choice A, "Do you think your anxiety is worse than everyone else's?", is invalidating and minimizes the client's experience. Comparing their anxiety to others is unhelpful and could further distress the client.
Choice B, "It doesn't appear as though you are feeling anxious.", is dismissive and ignores the client's self-report. This dismissive response could damage the therapeutic relationship and discourage the client from sharing openly.
Choice D, "I think you should see a therapist and a doctor tomorrow.", is directive and potentially premature. While suggesting mental health resources can be helpful, it's crucial to first understand the client's situation and preferences before making recommendations. Additionally, suggesting both a therapist and a doctor without further assessment might overwhelm the client.
Choice C, "Tell me what has been happening lately.", is an open-ended and validating that encourages the client to share their experiences and concerns. This shows the nurse is actively listening and creates a safe space for the client to explore their anxiety. By understanding the context and potential triggers, the nurse can then provide more tailored support and guidance.
Further rationale for Choice C:
Open-ended s are key tools in therapeutic communication. They promote client engagement, facilitate exploration of thoughts and feelings, and gather valuable information needed for assessment and planning.
Validating the client's experience is crucial in building trust and rapport. Recognizing and acknowledging their anxiety shows the nurse cares and is taking their concerns seriously.
This initial allows the client to guide the conversation, focusing on aspects they feel most comfortable sharing. This empowers the client and promotes autonomy.
Following the client's lead in the conversation also helps the nurse gather specific details about the nature and severity of the anxiety, informing subsequent assessment and intervention strategies.
In conclusion, Choice C, "Tell me what has been happening lately.", is the most appropriate response for a mental health nurse to use when assessing a client who reports an increase in anxiety. It demonstrates active listening, validates the client's experience, encourages engagement, and provides a foundation for further assessment and support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E","G"]
Explanation
The correct answer/s is Choice/s A, E, and G.
Choice A rationale: Administering 0.9% sodium chloride IV is a common practice in emergency departments to ensure the patient is well-hydrated. This is particularly important for patients experiencing acute mania, as they may have neglected their physical health, including hydration, during their manic episode.
Choice B rationale: Flumazenil is an antagonist for benzodiazepines and is typically used to reverse the sedative effects of benzodiazepines. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice C rationale: Preparing the client for intubation is usually reserved for situations where the patient is unable to maintain their own airway or adequate ventilation. This is not typically necessary in cases of acute mania unless there are other complicating factors.
Choice D rationale: Beginning chest compressions is a response to cardiac arrest. There is no indication in the that the patient is experiencing cardiac arrest, so this would not be a typical anticipation for a patient experiencing acute mania.
Choice E rationale: Administering IV naloxone is done in cases of suspected opioid overdose. While it’s not directly related to treating acute mania, it’s possible that the patient could have comorbid substance use issues, given the high rate of comorbidity between bipolar disorder and substance use disorders.
Choice F rationale: Administering activated charcoal is done in cases of certain types of poisoning or drug overdose. It is not typically used in the treatment of bipolar disorder or acute mania.
Choice G rationale: Preparing the client for electroconvulsive therapy (ECT) could be an appropriate anticipation for a patient experiencing acute mania. ECT is considered a highly effective treatment for severe mania, particularly when other treatments have failed or when rapid stabilization is required.
Correct Answer is C
Explanation
Choice A rationale:
While a client's unwillingness to accept treatment can be a challenge, it does not, in and of itself, meet the criteria for involuntary hospitalization beyond the initial 72-hour hold.
Forced treatment without a clear and imminent risk of harm can violate a patient's autonomy and rights.
It's crucial for healthcare professionals to balance a patient's right to self-determination with the need to protect individuals from harm.
Choice B rationale:
A client's plan to move out of state, even if it's considered a disruptive decision, does not constitute grounds for involuntary hospitalization.
Individuals have the right to freedom of movement and to make choices about their life, even if those choices are perceived as unwise or problematic.
Choice C rationale:
This is the correct answer because it aligns with the fundamental principle of involuntary hospitalization: to protect individuals who pose a serious risk of harm to themselves or others due to a mental health condition.
This rationale is rooted in the ethical and legal obligation to prevent harm and ensure public safety.
Choice D rationale:
A client's dislike of a neighbor is not a valid reason for involuntary hospitalization. Personal opinions or feelings, even if negative, do not automatically translate into a risk of harm that would justify involuntary confinement.
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