A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.
Which of the following actions should the nurse take?
Walk with the client at a gradually slower pace.
Have a staff member escort the client to her room.
Allow the client to pace alone until physically tired.
Instruct the client to sit down and stop pacing.
The Correct Answer is A
Rationale for Choice A:
Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.
Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.
Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.
Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.
Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.
Rationale for Choice B:
Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.
Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.
Rationale for Choice C:
Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.
Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.
Rationale for Choice D:
Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.
Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
Choice A is incorrect. Alprazolam does not have any known dietary interactions with aged cheeses. This information is specific to monoamine oxidase inhibitors (MAOIs), not benzodiazepines like alprazolam.
Choice B is incorrect. While some benzodiazepines can have side effects like drowsiness or dizziness that might indirectly affect blood pressure, alprazolam itself is not known to directly cause an increase in blood pressure.
Choice D is incorrect. Doubling the next dose of medication if a dose is missed is dangerous and can lead to overdose and increased risk of serious side effects. The client should be instructed to contact their doctor if they miss a dose.
Choice C is correct. Alprazolam is a pregnancy category D medication, meaning it has positive evidence of fetal risk. Studies have shown an increased risk of birth defects, including cleft lip and palate, in babies exposed to alprazolam during pregnancy. Therefore, it is crucial for women of childbearing age to use a reliable form of contraception while taking alprazolam to prevent unintended pregnancy and potential harm to the fetus.
Additional teaching points for the nurse:
The nurse should inform the client about the specific risks associated with alprazolam during pregnancy and the importance of discussing alternative treatment options if pregnancy is desired.
The nurse should emphasize the importance of using a reliable form of contraception that is effective both during and after treatment with alprazolam, as the medication can remain in the system for some time after the last dose.
The nurse should provide the client with resources on contraception and reproductive health, and encourage her to talk to her doctor about any s or concerns she may have.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: Expression of guilt feelings is a positive outcome in the treatment of conduct disorder. Guilt is an emotional response to one’s actions that are perceived as wrong or inappropriate. It is a self-conscious emotion that often involves a
sense of tension and regret. In the context of conduct disorder, the expression of guilt feelings can be seen as a sign of developing empathy and understanding the consequences of one’s actions. This is a crucial step in the process of behavior change and rehabilitation. The client showing signs of remorse during one-on-one counseling is a positive sign indicating that the treatment is having an effect.
Choice B rationale: A statement regarding unit rules is another positive outcome in the treatment of conduct disorder. Understanding and acknowledging the rules of the unit indicates that the client is beginning to accept the boundaries and norms set by the authority. This is a significant step towards improving their behavior, as individuals with conduct disorder often have difficulties following rules and respecting authority. The verbal altercation with another client could be seen as a negative event, but it also could indicate that the client is engaging with others, which could be a step towards improvement, depending on the context of the altercation.
Choice C rationale: A renewed relationship with an uncle does not necessarily indicate a positive outcome from the treatment of conduct disorder. While family support can be beneficial in the treatment process, it does not directly indicate that the client’s conduct disorder is improving. More information would be needed to determine if this is a positive outcome related to the treatment.
Choice D rationale: A positive attitude toward school is a positive outcome in the treatment of conduct disorder. School is a structured environment where rules and expectations are clearly laid out, and a positive attitude towards school can indicate that the client is beginning to accept these structures. This can be a sign of improvement in their behavior and attitude.
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