A mental health nurse is caring for a client who has schizophrenia and generalized anxiety disorder (GAD). The client has a prescription for lorazepam 2 mg PO every 6 hr PRN anxiety.
For which of the following client statements should the nurse consider administering lorazepam?

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.

The correct answer/s is:

C. Give positive feedback when the client is assertive with staff or clients.

Rationale for Choice A:

While setting limits is an important aspect of nursing care, it's not specifically targeted towards the core challenges of dependent personality disorder. The primary concern in this case is the client's excessive reliance on others and inability to function independently. Setting limits might be perceived as a rejection or abandonment, potentially exacerbating the client's distress and anxiety. Additionally, focusing on preventing the exploitation of other clients shifts the attention away from the client's individual needs and goals.

Rationale for Choice B:

While self-mutilation is a potential risk in some individuals with dependent personality disorder, it's not a defining characteristic or the most prevalent concern. Continuous close monitoring can be intrusive and undermine the client's sense of autonomy. It's more effective to build trust and establish open communication where the client feels comfortable expressing distress and seeking help before resorting to self-harm.

Rationale for Choice C:

Assertiveness is a key skill to cultivate in individuals with dependent personality disorder. It empowers them to express their needs and desires appropriately, reducing their reliance on others and fostering healthy relationships. Offering positive reinforcement when the client exhibits assertive behavior, even in small steps, strengthens this skill and motivates them to continue their progress. This positive reinforcement approach aligns with therapeutic interventions for dependent personality disorder, which focus on building self-confidence and fostering independent functioning.

Rationale for Choice D:

Discouraging flamboyant or seductive behaviors might seem relevant because some individuals with dependent personality disorder might resort to attention-seeking tactics. However, such an approach risks shaming or judging the client, potentially increasing their feelings of inadequacy and insecurity. It's important to understand the underlying reason behind these behaviors, which could be a desperate attempt to gain approval or validation. Addressing the core issue of low self-esteem and encouraging authentic self-expression are more productive strategies than simply suppressing certain behaviors.

Additional Notes:

In addition to the rationales for each choice, it's important to consider the overall treatment goals for dependent personality disorder. These goals typically include:

Reduced dependence on others: Encouraging the client to take responsibility for their own needs and decisions. Improved assertiveness skills: Enabling the client to express their wishes and opinions confidently.

Enhanced self-esteem: Building the client's confidence and sense of self-worth.

Developing healthy relationships: Fostering interactions based on mutual respect and independence.

When planning care for a client with dependent personality disorder, the nurse should collaborate with other healthcare professionals, such as therapists and social workers, to ensure a comprehensive and coordinated approach.