A nurse in a mental health facility is admitting a client.

Exhibits

A nurse is caring for a client who was admitted for alcohol use disorder, which of the following findings require follow-up by the nurse? Select all that apply.

Rationale for correct choices:

• Moderate anxiety: The client's symptoms, including irritability, restlessness, and a preoccupation with their thoughts (e.g., talking about "nice" clothes and the collection of toy cars), are more indicative of anxiety. The elevated heart rate and restlessness support this, as anxiety often causes physical symptoms like increased heart rate and difficulty focusing.
• Encourage the client to engage in physical activity: Physical activity helps reduce anxiety by promoting relaxation and offering an outlet for nervous energy. It can assist in reducing the client's restlessness and help manage anxiety symptoms.
• Encourage the client to problem solve: Anxiety often stems from feeling overwhelmed or out of control. Encouraging the client to problem-solve can help them feel more in control of their thoughts and reduce anxiety by breaking down issues into manageable steps.
• Heart rate: An elevated heart rate of 116 beats per minute is a common physiological response to anxiety. Monitoring heart rate helps gauge the severity of the client's anxiety and whether interventions are effective in managing it.
• Ability to focus on the task at hand: Anxiety often causes difficulty with concentration and focus, so assessing the client's ability to maintain attention can help determine the impact of their anxiety and the effectiveness of interventions.

Rationale for incorrect choices:

• Hoarding disorder: Although the client exhibits an interest in items from their childhood, there is no indication that they are accumulating items uncontrollably or have difficulty discarding things.
• Body dysmorphic disorder: While the client is focused on body image ("looking fit"), there is no evidence of extreme preoccupation with perceived flaws or a distorted view of their appearance, which is central to body dysmorphic disorder.
• Obsessive-compulsive disorder: Although the client is fidgeting and restless, these behaviors are more likely linked to anxiety rather than compulsions or rituals associated with OCD. The behavior doesn't suggest the obsessive, ritualistic patterns seen in OCD.
• Evaluate the client's ability to make decisions about their accumulated items: This action is more relevant for hoarding disorder. There is no indication that the client is accumulating items in an uncontrolled manner.
• Allow time for the client to complete ritualistic behavior: This is a strategy for OCD, where individuals feel compelled to complete specific rituals. The client's behavior is more related to anxiety and restlessness, not compulsive rituals.
• Observe the client's focus on body image: While the client seems to care about their appearance, there is no evidence of the intense preoccupation with body image or physical flaws that is characteristic of body dysmorphic disorder.
• Frequency of checking their reflection in a mirror: This is more relevant to body dysmorphic disorder, where the individual is preoccupied with their appearance. There is no evidence in this case that the client is excessively checking their reflection.
• Number of items purchased: This is a criterion for hoarding disorder, but there is no evidence in the scenario of the client purchasing or accumulating items uncontrollably.
• Ability to present for breakfast on time: This is not a key indicator for monitoring anxiety or OCD. Focusing on the ability to attend a meal does not address the core symptoms of anxiety in this case.

A. Intellectualization: Intellectualization involves using logic or reasoning to avoid emotional response to stress, but it is not the defense mechanism demonstrated here. The client is not using abstract thinking to avoid feelings but justifying behavior.

B. Introjection: Introjection involves internalizing the beliefs or values of others, which is not what is happening in this scenario. The client is not adopting someone else’s values but rationalizing their own actions.

C. Rationalization: Rationalization is the defense mechanism the client is using. The client is justifying their drinking as a way to cope with stress, making the behavior seem reasonable or acceptable even though it may be harmful.

D. Repression: Repression involves unconsciously blocking out uncomfortable thoughts or feelings, but the client is not denying their emotions or thoughts about stress. Instead, they are justifying their behavior, which aligns more with rationalization.