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: Identifying triggers for anxiety reactions is a crucial part of managing chronic anxiety. By recognizing what situations, thoughts, or feelings provoke anxiety, the client can begin to develop coping strategies to handle these triggers effectively. This approach is often used in cognitive-behavioral therapy, which is a common treatment for anxiety disorders.

Choice B rationale: While contacting a crisis counselor can be helpful in acute situations, it may not be necessary for a client with chronic anxiety to do so on a weekly basis. Regular therapy sessions with a mental health professional would likely be more beneficial, as they can provide ongoing support and help the client develop long-term coping strategies.

Choice C rationale: It’s unrealistic and unfeasible to completely eliminate stress and anxiety from daily life. Stress is a normal part of life, and everyone experiences it to some degree. Instead, the focus should be on managing stress and anxiety effectively through techniques such as relaxation exercises, mindfulness, and cognitive-behavioral strategies.

Choice D rationale: Trying to repress feelings of anxiety can actually exacerbate them. It’s important for individuals with anxiety disorders to acknowledge their feelings and learn how to manage them, rather than trying to suppress them. Repression can lead to increased anxiety and other mental health issues over time.

Choice A rationale:

Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:

1. Imminent Risk of Harm:

Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.

2. Physiological Manifestations:

Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure

Hyperventilation Diaphoresis

Agitation and restlessness Dissociation

These physiological changes can contribute to accidents, falls, or other injuries.

3. Impaired Decision-Making:

Acute anxiety often clouds rational thinking and decision-making abilities.

Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.

The nurse's role is to safeguard the client from potential consequences of these impulsive actions.

4. Establishing Safety as a Foundation for Care:

Ensuring physical safety creates a necessary foundation for subsequent interventions.

Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.

5. Protecting Others:

In rare cases, acute anxiety can manifest in aggression towards others.

The nurse must protect not only the client but also other individuals who may be at risk.

6. Ethical and Legal Obligations:

Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.

7. Preventing Trauma:

Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.

I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.