A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.

The client whispers to the nurse, “I’m being kept in this prison against my will.

Please try to get me out.” Which of the following responses should the nurse make?

“We are here to help you and give you the care that you need right now.”

“You feel that you don’t belong here?”

“Why do you feel that you need to leave?”

“Try to take some deep breaths and I’m sure you’ll feel better.”

Answer and Explanation

The Correct Answer is B

Choice A:

While this response is well-intentioned, it may not be the most therapeutic in this situation. It could be perceived as dismissive of the client's feelings and concerns. Clients with schizophrenia often have difficulty trusting others, and this response could reinforce the client's belief that they are being held against their will.

It's important to acknowledge the client's feelings and concerns, rather than simply stating that the healthcare team is there to help.

Choice B:

This response is the most therapeutic because it uses the technique of reflection. Reflection involves echoing back the client's feelings or thoughts, which can help them feel heard and understood. It can also encourage the client to elaborate on their concerns.

By reflecting the client's statement, the nurse validates their feelings and opens the door for further communication.

Choice C:

This response could be perceived as confrontational or challenging, which could further escalate the client's anxiety. It's generally more helpful to start with a more open-ended question or reflection.

Asking "why" questions can sometimes make people feel defensive or put on the spot.

Choice D:

While relaxation techniques can be helpful for some clients, this response is not appropriate in this situation. It minimizes the client's concerns and does not address their underlying feelings of fear and anxiety.

It's important to validate the client's feelings before suggesting coping strategies.

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Correct Answer is ["A","C","D"]

Explanation

Choice A rationale:

Seizures are a potentially serious complication of alcohol withdrawal. They occur due to the sudden decrease in GABA (gamma-aminobutyric acid), a neurotransmitter that has inhibitory effects on the central nervous system. Chronic alcohol consumption leads to an upregulation of GABA receptors in the brain to compensate for the depressant effects of alcohol. When alcohol is abruptly withdrawn, the brain is left in a hyperexcitable state, as there is less GABA to suppress neuronal activity. This hyperexcitability can manifest as seizures.

Mechanism of seizures in alcohol withdrawal:

Neuroadaptation: Chronic alcohol exposure leads to adaptations in neuronal excitability to counteract the depressant effects of alcohol. These adaptations include:

Upregulation of GABA receptors: The brain increases the number of GABA receptors to enhance the inhibitory effects of GABA.

Downregulation of glutamate receptors: The brain decreases the number of glutamate receptors to reduce the excitatory effects of glutamate.

GABA rebound: When alcohol is abruptly withdrawn, the upregulated GABA receptors become hypersensitive, leading to an excessive inhibitory response. This is known as GABA rebound.

Glutamate rebound: Concurrently, the downregulated glutamate receptors become more sensitive, leading to an enhanced excitatory response. This is known as glutamate rebound.

Imbalance: The combination of GABA rebound (excessive inhibition) and glutamate rebound (excessive excitation) creates a state of neuronal hyperexcitability, which can trigger seizures.

Risk factors for seizures in alcohol withdrawal:

Severity of alcohol dependence: Individuals with a long history of heavy alcohol consumption are at higher risk.

Previous alcohol withdrawal seizures: A history of seizures during past withdrawal episodes increases the likelihood of recurrence.

Comorbid medical conditions: Certain medical conditions, such as electrolyte imbalances, head injuries, or infections, can increase the risk of seizures.

Concurrent medication use: Certain medications, such as benzodiazepines or barbiturates, can lower the seizure threshold.

Management of seizures in alcohol withdrawal:

Benzodiazepines: Benzodiazepines are the mainstay of treatment for alcohol withdrawal seizures. They enhance the effects of GABA, helping to suppress neuronal excitability and prevent seizures.

Anticonvulsants: In some cases, anticonvulsants, such as gabapentin or valproate, may be used in addition to benzodiazepines.

Electrolyte replacement: Electrolyte imbalances, such as hyponatremia or hypomagnesemia, can contribute to seizures and should be corrected.

Monitoring: Close monitoring of vital signs, neurological status, and seizure activity is essential to ensure prompt intervention if seizures occur.

Choice B rationale:

Nystagmus, or involuntary eye movements, is not a common symptom of alcohol withdrawal. While it can occur in some cases, it is not considered a primary feature of the syndrome.

Choice C rationale:

Tremors are a very common symptom of alcohol withdrawal. They are caused by the same underlying mechanism as seizures, namely, the hyperexcitability of the central nervous system due to decreased GABA activity. Tremors typically manifest as shaking hands, arms, or legs, and can range in severity from mild to severe.

Choice D rationale:

Hallucinations, both auditory and visual, can occur in alcohol withdrawal. They are thought to be due to a combination of factors, including the hyperexcitability of the central nervous system, disruptions in neurotransmitter systems, and sleep deprivation. Hallucinations can be very distressing and can lead to agitation, confusion, and disorientation.

A. Stating that he wants to be with his peers more than with his parents. B. Telling his parents that he doesn’t want to talk about the attempt. C. Preferring to eat his meals while watching TV. D. Planning to give his CD collection to his girlfriend.

Correct Answer is D

Explanation

Planning to give away prized possessions is a significant warning sign of potential suicide. This behavior often signals that the individual is preparing for death and believes they will no longer need those items. It's a concerning indication that they may have made a decision to end their life and are putting their affairs in order.

Here's a detailed breakdown of why this behavior is so concerning:

Final Arrangements: Giving away cherished belongings suggests a sense of finality and a belief that there's no future to look forward to. It's a way of detaching from material possessions and preparing for a perceived ending.

Loss of Interest: When someone loses interest in activities or items they previously valued, it can reflect a profound loss of hope and a withdrawal from life. This detachment is often a feature of suicidal ideation.

Saying Goodbye: Distributing belongings can serve as a symbolic way of saying goodbye to loved ones without explicitly stating suicidal intentions. It's a nonverbal communication of their plans, often done to avoid intervention or to ease the burden on others after their death.

Lack of Self-Preservation: The act of giving away possessions demonstrates a disregard for one's own future needs and a lack of investment in their continued existence. It suggests a mindset that they won't be around to enjoy those items any longer.

No Hope for Change: This behavior can also signal a belief that their circumstances are hopeless and that suicide is the only viable solution. It reflects a sense of despair and a conviction that things won't improve.

It's crucial to note that not all individuals who contemplate suicide will exhibit this specific behavior. However, it's a serious red flag that should never be ignored. If you witness someone giving away their possessions, it's imperative to take immediate action to assess their safety and seek professional help.

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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I’m being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?

Nursing Test Bank

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Correct Answer is ["A","C","D"]

Explanation

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Correct Answer is D

Explanation

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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.

The client whispers to the nurse, “I’m being kept in this prison against my will.

Please try to get me out.” Which of the following responses should the nurse make?