A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.
Which of the following actions should the nurse take?

Walk with the client at a gradually slower pace.

Have a staff member escort the client to her room.

Allow the client to pace alone until physically tired.

Instruct the client to sit down and stop pacing.

Answer and Explanation

The Correct Answer is A

Rationale for Choice A:

Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.

Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.

Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.

Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.

Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.

Rationale for Choice B:

Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.

Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.

Rationale for Choice C:

Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.

Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.

Rationale for Choice D:

Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.

Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.

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Correct Answer is B

Explanation

Choice A rationale: Providing privacy when friends visit is a general good practice in nursing. However, it may not be the most effective intervention for a client with anorexia nervosa. Anorexia nervosa is characterized by a distorted body image and an intense fear of gaining weight. While privacy is important, it is not directly related to the management of anorexia nervosa.

Choice B rationale: Scheduling regular weigh-in times is a key intervention for clients with anorexia nervosa. Regular weigh-ins help monitor the client’s progress and any potential complications related to weight loss. This intervention is directly related to the management of anorexia nervosa and is therefore the correct answer.

Choice C rationale: Complimenting the client for weight gain can be a sensitive issue for individuals with anorexia nervosa. While it might seem like a positive reinforcement, it could potentially trigger anxiety and fear in the client, as individuals with anorexia nervosa have an intense fear of gaining weight. Therefore, this intervention should be handled with care and is not the best choice in this scenario.

Choice D rationale: Allowing the client to eat at any time might seem like a good idea, but it is not the most effective intervention for a client with anorexia nervosa. Individuals with anorexia nervosa often have strict rituals and rules around eating. Allowing them to eat at any time might not address these underlying issues and could potentially enable their disordered eating habits.

A. A client who has Obsessive Compulsive Disorder (OCD) and insists on mopping the floor in the day room. B. A client who has a personality disorder and tries to manipulate the staff to gain privileges. C. A client who has Bulimia Nervosa and refuses to come to the dining room for meals. D. A client who is just recovering from a benzodiazepine overdose.

Correct Answer is D

Explanation

Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive

thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.

Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.

While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.

Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.

Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.

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A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?

Correct Answer is B

Explanation

A mental health nurse is planning care for a group of clients.Which of the following clients should the nurse identify as having a contraindication for applying restraints?

Correct Answer is D

Explanation

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A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.
Which of the following actions should the nurse take?