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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer(s) is/are:
C. Telling his parents that he doesn't want to talk about the suicide attempt.
Rationale:
Choice A: Planning to give his Xbox console to his best friend.
While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.
Choice B: Stating that he wants to be with his peers more than with his parents.
This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.
Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:
Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.
Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.
Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.
Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.
Choice D: Preferring to eat his meals while watching TV.
This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.
Conclusion:
Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.
Correct Answer is B
Explanation
Choice A rationale:
Obsession over a fictitious defect in physical appearance is characteristic of body dysmorphic disorder, not generalized anxiety disorder (GAD).
Individuals with body dysmorphic disorder become preoccupied with an imagined or slight defect in their appearance, often to the point of significant distress and impairment in functioning.
They may engage in excessive grooming behaviors, repeatedly check their appearance in mirrors, or avoid social situations due to their appearance concerns.
While individuals with GAD may also experience concerns about their physical appearance, these concerns are typically not as severe or pervasive as those seen in body dysmorphic disorder.
Choice B rationale:
Constant worry about the undiagnosed presence of an illness is a hallmark feature of GAD.
Individuals with GAD often experience excessive worry about a variety of things, including health, finances, relationships, and work.
This worry is often accompanied by physical symptoms such as restlessness, fatigue, difficulty concentrating, and muscle tension.
The worry is typically difficult to control and can significantly interfere with daily life.
Choice C rationale:
Sudden unexplained loss of vision without a physical medical explanation is not a common symptom of GAD. It may be indicative of a more serious medical condition, such as a stroke or a neurological disorder.
It is important to rule out any potential medical causes before attributing a symptom like this to GAD.
Choice D rationale:
Prior physical health followed by the need for two surgeries within the last three months may be a stressful life event that could contribute to the development of GAD.
However, it is not a specific symptom of GAD.
Many people experience stressful life events without developing GAD.
The presence of other symptoms, such as excessive worry and physical symptoms, is necessary for a diagnosis of GAD.
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