A mental health nurse is caring for a client who has schizophrenia and generalized anxiety disorder (GAD). The client has a prescription for lorazepam 2 mg PO every 6 hr PRN anxiety.
For which of the following client statements should the nurse consider administering lorazepam?

Choice A rationale:

Intrusive and judgmental: Asking "Why did you wear clean clothes and comb your hair today?" directly challenges the client's behavior and implies that she needs to justify her actions. This can make the client feel defensive and less likely to open up.

Focuses on the past: The directs attention to the client's previous lack of self-care, which can reinforce negative feelings and discourage progress.

Assumes motivation: It presumes that the client made a conscious decision to change her appearance based on a specific reason, which may not be accurate and can invalidate her experience.

Choice B rationale:

Presumptuous and premature: Concluding that "Your mood must be lifting because you have on clean clothes and have combed your hair" makes assumptions about the client's internal state without proper assessment.

Oversimplifies depression: It suggests that improvements in self-care directly equate to mood improvement, which disregards the complexity of depression and its varied manifestations.

Can create pressure: The statement can inadvertently pressure the client to feel or act a certain way to meet the nurse's expectations, hindering genuine progress.

Choice D rationale:

Paternalistic and condescending: Expressing "Oh, I'm so pleased that you finally put on clean clothes" implies that the nurse has been waiting for or expecting this change, placing the nurse in a position of authority and potentially undermining the client's autonomy.

Focuses on the nurse's feelings: The statement centers on the nurse's approval rather than acknowledging the client's efforts and perspective.

Can reinforce dependency: It can foster a dynamic where the client seeks external validation for her actions, rather than developing internal motivation for self-care.

Choice C rationale:

Observational and non-judgmental: The statement "I see that you have on clean clothes and have combed your hair" simply acknowledges the client's actions without imposing any interpretation or judgment.

Invites conversation: It provides an opportunity for the client to elaborate on her choices if she feels comfortable, promoting autonomy and self-expression.

Validates effort: It subtly recognizes the client's efforts without explicitly praising or criticizing, fostering a sense of self- efficacy and encouraging continued self-care.

Demonstrates active listening: It shows that the nurse has been paying attention to the client's progress, which can strengthen the therapeutic relationship and build trust.

Rationale:

A. Agoraphobia: This choice directly aligns with the client's presentation of being afraid to leave her home alone. Agoraphobia is a specific phobia characterized by an intense fear of situations that the individual perceives as inescapable or that might potentially lead to panic or embarrassment. Common triggers for agoraphobic individuals include crowded spaces, open spaces, public transportation, or being alone outside of the home. The client's inability to leave her home for weeks due to fear is a classic symptom of agoraphobia.

B. Xenophobia: This choice refers to the fear of strangers or foreigners. While the client may experience anxiety in unfamiliar situations, the primary focus of her fear is being outdoors alone rather than encountering unfamiliar people. Additionally, the daughter's description of the client's fear specifically mentions being alone, further supporting agoraphobia as the more likely diagnosis.

C. Mysophobia: This choice refers to an extreme or obsessive fear of germs or contamination. While anxiety related to cleanliness could coexist with agoraphobia, the primary presenting complaint in this case is the fear of being outdoors, not specifically germs or contamination.

D. Aerophobia: This choice refers to the fear of flying or being in high places. There is no indication in the scenario that the client's fear is specifically related to heights or flying, making this choice less likely.

Therefore, based on the specific nature of the client's fear and the limited information provided, agoraphobia is the most probable diagnosis and the one the nurse should anticipate planning care for.