A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Choice A rationale:

Repression: This statement suggests that the client is unconsciously blocking out memories of the tragedy as a way to cope with the anxiety. While repression can be a defense mechanism, it's not considered an adaptive use of sublimation.

Sublimation involves channeling anxiety into a productive or socially acceptable activity.

Denial of anxiety: The client's denial of anxiety, despite outward signs of distress, indicates a lack of awareness or acceptance of their emotional state. This can hinder effective coping and processing of the trauma.

Potential for delayed or prolonged distress: Repressed memories can resurface later, often in unexpected or disruptive ways, potentially leading to prolonged or intensified distress.

Choice B rationale:

Hopelessness and helplessness: The client's statement reflects a sense of defeat and a belief that they are incapable of overcoming the trauma. This can lead to feelings of despair, isolation, and withdrawal.

Lack of adaptive coping mechanisms: The client's inability to envision a future beyond the tragedy suggests a lack of healthy coping strategies to manage their anxiety and move forward.

Risk of prolonged distress and potential for depression: Persistent feelings of hopelessness and helplessness can increase the risk of developing depression or other mental health conditions.

Choice C rationale:

Denial of anxiety and potential lack of insight: The client's denial of anxiety, despite the nurse's observation, suggests a lack of awareness or acceptance of their emotional state. This can impede effective coping and processing of the trauma.

Potential resistance to support: The client's defensiveness may make it challenging for them to receive support or engage in therapeutic interventions.

Risk of delayed or unmanaged distress: If the client continues to deny their anxiety, they may not seek appropriate help, potentially leading to prolonged or intensified distress.

Choice D rationale:

Sublimation: This statement demonstrates the client's ability to channel their anxiety into a constructive and healthy outlet. Physical activity can provide a release for pent-up emotions, reduce stress, and improve overall well-being.

Adaptive coping mechanism: The client's choice to engage in physical activity as a way to manage their emotions indicates a positive coping strategy that can promote resilience and recovery.

Potential for improved mental and physical health: Regular exercise has numerous benefits for both mental and physical health, which can support the client's overall well-being and recovery process.

Choice A rationale: Giving the client a PRN sleeping medication is not the best option in this situation. While it might help the client sleep, it does not address the underlying issue causing the client’s anxiety and restlessness. It’s important to remember that medication should not be the first line of treatment unless necessary. Instead, non- pharmacological interventions should be explored first.

Choice B rationale: Encouraging the client to go back to bed might seem like a reasonable action. However, it might not be helpful if the client is feeling restless and anxious. Forcing the client to stay in bed might increase their anxiety and restlessness. It’s important to address the client’s feelings and provide comfort and reassurance.

Choice C rationale: Remaining with the client is the best action to take in this situation. The client is showing signs of anxiety and restlessness, and the presence of the nurse can provide comfort and reassurance. The nurse can use this time to talk to the client, understand their concerns, and provide emotional support. This can help to alleviate the client’s anxiety and might make it easier for them to relax and eventually sleep.

Choice D rationale: Exploring alternatives to pacing the floor with the client might be a good option, but it’s not the best initial action. While it’s important to provide the client with alternatives to help manage their anxiety, the first step should be to provide comfort and reassurance. Once the client is feeling calmer, the nurse can then discuss different strategies to help manage their anxiety.