A nurse is attending to a client experiencing acute anxiety.
Which of the following actions should the nurse undertake? (Select all that apply.)

Establish rapport with the client.

Avoid making eye contact when addressing the client.

Speak to the client using a high-pitched voice.

Validate the client’s feelings and identify the cause of the anxiety.

Answer and Explanation

Correct Answer : A,D

Choice A rationale:

Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:

Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.

Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.

Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.

Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.

Techniques for establishing rapport:

Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.

Empathy: Show understanding and compassion for the client's experiences and feelings.

Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.

Genuineness: Be authentic and honest in your interactions with the client.

Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.

Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.

Choice B rationale:

Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.

Choice C rationale:

Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.

Choice D rationale:

Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.

Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.

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

Explanation

Answer and explanation The correct answers are:

Condition:

Mania Actions:
Daily weight

D. Suicidal behavior

Parameters to monitor:

Blood pressure and pulse rate

Food intake during meals

Rationale for condition:

Choice A: Mania

The client's presentation is consistent with the manic phase of bipolar disorder.

Key features of mania include:

Elevated mood or irritability

Increased energy and activity levels

Racing thoughts and rapid speech

Decreased need for sleep Impulsive behavior

Distractibility

Poor judgment

Grandiosity

Auditory hallucinations Rationale for actions:

Choice B: Daily weight

Weight loss is a common symptom of mania due to increased activity levels and decreased appetite.

Monitoring weight helps assess the severity of mania and the need for nutritional interventions.

Choice D: Suicidal behavior

Individuals with bipolar disorder are at increased risk for suicide, especially during manic episodes.

Close monitoring for suicidal ideation and behavior is crucial for safety.

Rationale for parameters to monitor:

Choice A: Blood pressure and pulse rate

Mania can lead to physiological changes such as increased heart rate and blood pressure.

Monitoring these vital signs helps assess the physical impact of mania and the potential need for medical interventions.

Choice C: Food intake during meals

As mentioned, decreased appetite is common in mania.

Monitoring food intake ensures adequate nutrition and prevents dehydration.

A. “I mentally separate myself from distractions around me when I paint on canvas.” B. “I wrote a short story about a heroic woman when I was really mad at my boss.” C. “I still cannot remember the scene of my husband’s car accident.” D. “I don’t care about work anymore since I was not given a promotion.”

Correct Answer is D

Explanation

Choice A rationale:

Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.

It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.

It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.

Choice B rationale:

Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.

It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.

It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.

Choice C rationale:

Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.

It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.

It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.

Choice D rationale:

Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.

It reflects an inability to cope with disappointment or setbacks in a constructive way.

It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.

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A nurse is attending to a client experiencing acute anxiety. Which of the following actions should the nurse undertake? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

During a group therapy session, a nurse observes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the use of maladaptive coping mechanisms?

Correct Answer is D

Explanation

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A nurse is attending to a client experiencing acute anxiety.
Which of the following actions should the nurse undertake? (Select all that apply.)