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 ["A","B","C"]

Explanation

The correct answer/s is Choices A, B, and C.

Choice A Rationale:

Recent or impending moves can be a significant stressor for adolescents, disrupting their social networks, routines, and sense of belonging. This disruption can exacerbate existing mental health problems or trigger new ones, increasing the risk of suicidal ideation or behavior. Studies have shown that adolescents who relocate are more likely to experience depression, anxiety, and substance abuse, all of which are risk factors for suicide. Additionally, the feeling of loss and displacement associated with moving can lead to feelings of isolation and hopelessness, further increasing the risk.

Choice B Rationale:

A sudden decline in school performance can be a sign of underlying emotional distress in adolescents. This decline may be due to depression, anxiety, or other mental health problems that can impede concentration, motivation, and overall academic functioning. Suicidal ideation or behavior can also lead to a decline in school performance as the adolescent withdraws from their usual activities and struggles to cope with their emotions. Therefore, a sudden drop in grades or academic engagement should raise a red flag for the nurse and warrant further investigation into the adolescent's emotional well-being.

Choice C Rationale:

The death of a parent at a young age is a major life event that can have a profound impact on an adolescent's emotional and psychological development. This loss can lead to feelings of grief, sadness, anger, and isolation, all of which are risk factors for suicide. Additionally, adolescents who lose a parent may be more likely to experience depression, anxiety, and substance abuse, further increasing their vulnerability to suicidal thoughts and behaviors. The nurse should be particularly concerned if the death of the parent was recent or if the adolescent has not adequately processed their grief.

Choice D Rationale:

While low parental expectations can be a negative influence on an adolescent's self-esteem and motivation, it is not directly linked to an increased risk of suicide. In fact, some studies have suggested that high parental expectations can be equally detrimental to adolescent mental health. Therefore, while low parental expectations may not be a standalone risk factor for suicide, it is important to consider this factor in the context of the adolescent's overall psychosocial assessment.

Summary:

A recent or impending move, a sudden decline in school performance, and the death of a parent at a young age are all significant stressors that can increase the risk of suicidal ideation or behavior in adolescents. The nurse should be alert to these warning signs and conduct a thorough psychosocial assessment to identify any underlying mental health issues or risk factors. Early intervention and support can significantly reduce the risk of suicide and help adolescents cope with these challenging life events.

A. "She is always bossing me around. Should she do that?" B. "Please do not raise your voice at the children. I am the one who left dishes in the sink." C. "If you keep saying that, I will tell everyone what you did last night." D. "Can you tell me the reason you get upset each time you go to the mall?".

Correct Answer is D

Explanation

Choice A rationale:

This statement is accusatory and blaming, rather than promoting understanding and problem-solving. It focuses on the negative behavior of the sibling and seeks external validation for the speaker's feelings, rather than attempting to address the underlying issue directly with the sibling.

It uses "should" language, which can come across as judgmental and critical, potentially escalating conflict.

It does not express the speaker's own feelings or needs, making it difficult for the other person to understand and respond effectively.

Choice B rationale:

While this statement demonstrates a willingness to take responsibility for actions, it does not directly address the communication between the family members. It focuses on redirecting the father's anger rather than exploring the underlying reasons for the conflict.

It could be interpreted as silencing the children's voices and potentially reinforcing a hierarchical dynamic within the family, where one parent holds authority over the others.

Choice C rationale:

This statement is manipulative and threatening, using a fear of exposure to control the other person's behavior. It undermines trust and safety within the family, making it difficult to have open and honest communication.

It does not address the core issue at hand and instead escalates conflict by using a "tit-for-tat" approach.

Choice D rationale:

This statement effectively demonstrates several key principles of effective communication: It expresses curiosity and a genuine desire to understand the other person's perspective.

It avoids accusations or assumptions, instead inviting open dialogue.

It focuses on specific behaviors and events ("each time you go to the mall") rather than making sweeping generalizations about the person's character.

It uses "I" language to express the speaker's own feelings and concerns, inviting empathy and understanding.

It creates an opportunity for the other person to share their perspective and work towards a resolution together.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

During a family therapy session led by a nurse, which of the following statements should be recognized as an example of effective communication among a mother, father, and two adolescent siblings?

Correct Answer is D

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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?