A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

Confirming boundaries by setting limits on behavior.

Providing reality orientation.

Providing client education in a direct manner.

Ensuring physical need fulfillment.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Confirming boundaries by setting limits on behavior.

This response is correct because it directly addresses the need to set clear boundaries with the client. In a psychiatric setting, it is crucial to establish and maintain professional boundaries to ensure a therapeutic environment. By limiting the client’s approach to the nurse’s station, the nurse is setting a clear boundary that helps manage the client’s behavior and ensures that the nurse can attend to other patients as well. This intervention helps in maintaining structure and predictability, which can be very beneficial for clients with psychiatric conditions.

Choice B Reason:

Providing reality orientation.

Providing reality orientation involves helping clients understand their surroundings and current situation, often used for clients with cognitive impairments or disorientation. While important, this intervention does not specifically address the behavior of frequently approaching the nurse’s station. Reality orientation would be more relevant in cases where the client is confused about time, place, or person.

Choice C Reason:

Providing client education in a direct manner.

Providing client education is essential, but it does not directly relate to setting behavioral limits. Education might involve explaining the reasons behind certain rules or treatments, but it does not address the immediate need to manage the client’s frequent requests. The intervention described in the question is more about behavior management than education.

Choice D Reason:

Ensuring physical need fulfillment.

Ensuring physical need fulfillment involves addressing the client’s basic needs such as food, hydration, and comfort. While this is a fundamental aspect of nursing care, it does not relate to setting behavioral limits or managing the frequency of the client’s requests. The intervention in the question is focused on managing behavior rather than fulfilling physical needs.

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Correct Answer is A

Explanation

Choice A Reason:

Seclusion is used in psychiatric settings primarily to manage patients who are exhibiting aggressive or severely disturbed behavior. The reduced sensory input in a seclusion room helps the patient to regain control over their emotions and behavior by minimizing external stimuli that could exacerbate their condition. This controlled environment can be crucial in preventing harm to the patient and others, and it allows the patient to calm down in a safe space. The goal is to provide a therapeutic setting that aids in the patient’s recovery and stabilization.

Choice B Reason:

While communication is an essential part of psychiatric care, seclusion is not intended to encourage interaction with others. In fact, seclusion is used when a patient needs to be isolated to prevent harm to themselves or others. Encouraging communication is more appropriate in other therapeutic settings where the patient is stable and can engage safely with others. Therefore, this statement does not accurately explain the purpose of seclusion.

Choice C Reason:

Forcing clients to be responsible for themselves is not the primary goal of seclusion. Seclusion is a measure taken to ensure safety and to help the patient regain control over their behavior in a controlled environment. Responsibility and self-management are important aspects of psychiatric treatment, but they are typically addressed through other therapeutic interventions and not through seclusion. Thus, this statement is not an accurate explanation of the use of seclusion.

Choice D Reason:

Managing the unit with fewer staff is not a valid reason for using seclusion. The primary purpose of seclusion is to ensure the safety of the patient and others, not to reduce staffing needs. In fact, the use of seclusion requires careful monitoring and adherence to strict protocols, which can actually increase the need for staff attention. Therefore, this statement does not correctly explain the rationale behind the use of seclusion.

A. Recognize signs of escalating anxiety. B. Avoid all situations that cause stress. C. Recognize that they need to take medications as ordered. D. Utilize relaxation techniques to limit anxiety. E. Discuss plans to handle panic attacks if they occur.

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

Explanation

Choice A Reason:

Recognizing signs of escalating anxiety is a crucial skill for clients with GAD. This awareness allows them to identify early warning signs and implement coping strategies before anxiety becomes overwhelming. Early recognition can prevent the escalation of symptoms and reduce the impact on daily functioning. This skill is often developed through cognitive-behavioral therapy (CBT) and other therapeutic interventions that focus on self-awareness and self-monitoring.

Choice B Reason:

Avoiding all situations that cause stress is not a practical or effective strategy for managing GAD. While it is important to reduce unnecessary stress, complete avoidance can lead to increased anxiety and avoidance behaviors, which can worsen the disorde. Instead, clients are encouraged to develop coping strategies to manage stress and face anxiety-provoking situations gradually5. This approach helps build resilience and reduces the overall impact of anxiety on their lives.

Choice C Reason:

Recognizing the need to take medications as ordered is essential for effective management of GAD. Medication adherence ensures that the client maintains therapeutic levels of medication, which can help control symptoms and prevent relapse. Non-adherence to medication regimens is a common issue in mental health treatment and can lead to worsening symptoms and increased risk of hospitalization. Therefore, understanding and adhering to prescribed medications is a key component of effective care.

Choice D Reason:

Utilizing relaxation techniques to limit anxiety is a highly effective strategy for managing GAD. Techniques such as deep breathing, progressive muscle relaxation, and mindfulness can help reduce physiological arousal and promote a sense of calm. These techniques are often taught in therapy and can be practiced regularly to help manage anxiety symptoms. Incorporating relaxation techniques into daily routines can significantly improve the client’s ability to cope with stress and anxiety.

Choice E Reason:

Discussing plans to handle panic attacks if they occur is an important aspect of managing GAD. Having a clear plan in place can help the client feel more in control and reduce the fear of experiencing a panic attack. This plan may include strategies such as deep breathing, grounding techniques, and seeking support from trusted individuals. By preparing for potential panic attacks, clients can reduce their overall anxiety and improve their ability to manage symptoms effectively.

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A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in orientation is rotating to a psychiatric unit where they observe a client in seclusion. Which of the following statements by the nurse’s preceptor best explains the use of seclusion on a unit?

Correct Answer is A

Explanation

The nurse who has been caring for a client with generalized anxiety disorder (GAD) recognizes that care has been effective when the client is able to: (SELECT ALL THAT APPLY)

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

Explanation

A nurse working on a psychiatric unit is providing care for a client that reports feeling irritable and distressed. The client states, “I just feel so helpless.” Which of the following statements most aligns with the client’s presentation of neurotic behavior?

An inpatient client who has a known history of violence suddenly begins to pace. Which additional client behavior should alert the nurse to escalating anger and aggression? The client:

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Which action should the nurse take prior to educating clients about relaxation techniques?

A nurse is reviewing assessment data collected from a post-operative patient. What assessment findings would serve as cues that the client may be experiencing hypoactive delirium? Select all that apply.

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?

A client asks the nurse to promise to keep confidential a plan they have to kill their father. Which of the following statements would be the best response for the nurse to make?