A nurse working in an outpatient mental health facility is caring for a client who has anxiety and was discharged from an inpatient mental health facility 1 week ago.
A nurse in an outpatient mental health facility is assessing a client who has anxiety. Click to highlight the findings in the Nurses’ Notes that indicate an improvement in the client’s condition. To deselect a finding, click on the finding again.
Client appears to be well-groomed.
Client’s current weight is 54 kg (119 lb).
Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Verbalizes decreased appetite and gastrointestinal discomfort.
Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Verbalizes that bullying experienced during high school has led to anxiety.
Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
Client appears to be well-groomed.
Client’s current weight is 54 kg (119 lb).
Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Verbalizes decreased appetite and gastrointestinal discomfort.
Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Verbalizes that bullying experienced during high school has led to anxiety.
Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
The Correct Answer is ["A","C","G","H"]
Choice A: Client appears to be well-groomed.
Reason: Being well-groomed can indicate that the client is taking care of their personal hygiene and appearance, which is often a sign of improved mental health and self-esteem. This is particularly relevant for clients with anxiety or depression, as neglecting personal care can be a symptom of these conditions.
Choice B: Client’s current weight is 54 kg (119 lb).
Reason: The client’s weight has remained stable since admission (54.4 kg to 54 kg). While this indicates no further weight loss, it does not necessarily indicate an improvement in anxiety symptoms. Weight stability alone is not a direct indicator of mental health improvement.
Choice C: Client states they are sleeping 5 to 6 hours per night but having an occasional nightmare.
Reason: An increase in sleep duration from 3-4 hours to 5-6 hours per night suggests an improvement in the client’s sleep pattern, which is a positive sign in managing anxiety. Occasional nightmares are still present, but the overall increase in sleep is beneficial.
Choice D: Verbalizes decreased appetite and gastrointestinal discomfort.
Reason: Continued decreased appetite and gastrointestinal discomfort indicate ongoing anxiety symptoms. These are not signs of improvement and suggest that the client is still experiencing significant anxiety.
Choice E: Client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.”
Reason: This statement reflects ongoing social anxiety and fear of judgment, indicating that the client is still struggling with anxiety symptoms. This is not an indicator of improvement.
Choice F: Verbalizes that bullying experienced during high school has led to anxiety.
Reason: Acknowledging the source of anxiety (bullying) is important for therapy, but it does not directly indicate an improvement in the client’s current anxiety symptoms.
Choice G: Client engages in thought-stopping behavioral therapy and cognitive restructuring.
Reason: Active participation in therapeutic techniques like thought-stopping and cognitive restructuring indicates that the client is engaging in strategies to manage and reduce anxiety. This is a positive sign of improvement.
Choice H: Client reports taking escitalopram 20 mg daily 2 hr after breakfast.
Reason: Consistent medication adherence is crucial for managing anxiety symptoms. The client’s regular intake of escitalopram suggests they are following their treatment plan, which is a positive indicator of improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The statement "Don't worry about it. Your anxiety will lessen once the massage begins" is not appropriate. This response dismisses the client's expressed discomfort and does not address their concerns. It is important to validate the client's feelings and work collaboratively to find an acceptable alternative.
Choice B reason:
The statement "I will request that the massage therapist wear gloves during your treatment" is not a suitable solution. Wearing gloves may not alleviate the client's discomfort with being touched and could still cause anxiety. It is better to explore other treatment options that do not involve physical contact.
Choice C reason:
The statement "Why don't you like to be touched by others?" is not the best approach. While understanding the client's reasons can be helpful, this question may come across as intrusive or judgmental. It is more important to respect the client's boundaries and preferences.
Choice D reason:
The statement "I will tell your provider that you would like a treatment other than massage" is the correct response. This response acknowledges the client's discomfort and takes appropriate action to find an alternative treatment that the client is comfortable with. It shows respect for the client's preferences and ensures their needs are met.
Correct Answer is A
Explanation
Choice A Reason:
This response is open-ended and encourages the client to express their feelings and thoughts. It shows empathy and allows the nurse to gather more information about the client's emotional state. Open-ended questions are crucial in therapeutic communication as they help build rapport and trust, which are essential in managing clients with major depressive disorder. According to nursing guidelines, assessing the client's feelings and thoughts is a primary step in understanding their mental health status and planning appropriate interventions.
Choice B Reason:
Asking "Why did you feel like giving away your belongings?" might come across as judgmental or confrontational. It could make the client feel defensive or misunderstood. In therapeutic communication, it's important to avoid "why" questions as they can imply criticism and may not encourage the client to open up. Instead, focusing on the client's feelings and experiences is more effective in understanding their condition.
Choice C Reason:
Saying "Everyone feels a little down sometimes" minimizes the client's feelings and can be perceived as dismissive. Clients with major depressive disorder often feel isolated and misunderstood, and such a response could exacerbate these feelings. It's important for nurses to validate the client's emotions and provide support rather than downplaying their experiences.
Choice D Reason:
While suggesting a support group can be helpful, it is not the most immediate or appropriate response in this context. The client has expressed a significant behavior (giving away personal belongings) that could indicate suicidal ideation or severe depression. The nurse's priority should be to assess the client's current emotional state and risk factors before suggesting long-term solutions like support groups.
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