A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Administer an anti-anxiety medication.

Explore behaviors that have helped to reduce the client's anxiety in the past.

Minimize environmental stimuli in the client's surroundings.

Explain to the client that anxiety causes physical manifestations

Answer and Explanation

The Correct Answer is C

The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.

While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.

Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.

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Correct Answer is A

Explanation

Displacement is a defense mechanism where a person redirects their emotional impulses, such as anger or frustration, from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting their anger towards the nurse when medication changes are prescribed by the provider. The nurse becomes the target of the client's anger, even though the nurse is not directly responsible for the medication changes.

Conversion is a defense mechanism where psychological distress is expressed as physical symptoms or ailments.

Splitting is a defense mechanism where a person sees things as either all good or all bad, with no middle ground or ambivalence.

Sublimation is a defense mechanism where unacceptable impulses or behaviors are channeled into socially acceptable and constructive outlets.

A. "Why do you feel the staff is the FBI?" B. "The psychiatric staff is not FBI. They are here to help you."" C. "This must be very frightening for you. Let's talk more about it." D. "What makes you think the staff is following you?"

Correct Answer is C

Explanation

When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.

The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.

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A nurse in a mental health facility is caring for a client who reports palpitations and a sense of impending doom. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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