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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is choice c. “In my dreams, all I can see are the wounded reaching out and trying to grab me.”

Choice A rationale:

This statement indicates hypervigilance and paranoia, which can be symptoms of PTSD, but it is more indicative of a delusional disorder or severe anxiety.

Choice B rationale:

This statement reflects a possible delusion of grandeur or a coping mechanism to deal with trauma, but it does not directly indicate PTSD.

Choice C rationale:

This statement describes a recurring nightmare, which is a common symptom of PTSD. Individuals with PTSD often relive traumatic events through nightmares or flashbacks.

Choice D rationale:

This statement suggests a belief in a cause-and-effect relationship that may not be accurate. It could indicate guilt or a misunderstanding of the situation, but it is not a direct symptom of PTSD.

A. Behavioral contract B. Dialectical behavior therapy C. Safety plan D. Bibliotherapy.

Correct Answer is B

Explanation

The correct answer is choice B.

Choice A rationale:

“Behavioral contract.” While a behavioral contract can be a useful tool in managing certain behaviors, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.

Choice B rationale:

“Dialectical behavior therapy.” This is the correct answer. Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy that is specifically designed to help people with borderline personality disorder. It focuses on teaching coping skills to combat destructive urges, encourages mindfulness, improves relationships, and helps with emotional regulation.

Choice C rationale:

“Safety plan.” While a safety plan is important for all clients, it is not the primary intervention for a client with borderline personality disorder. A safety plan is more commonly used for clients who are at risk of self-harm or suicide.

Choice D rationale:

“Bibliotherapy.” Bibliotherapy, the use of books as therapy, can be a useful adjunctive treatment for some individuals. However, it is not typically the primary intervention used in the discharge planning for a client with borderline personality disorder.

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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?

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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?