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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
The correct answer/s is Choice/s.
Choice A rationale: Requesting to decrease the dose of oral glycemic medication might not be the most appropriate action for the nurse to take. The client reports overeating since they were 14 years old, which could potentially lead to obesity and related health issues such as type 2 diabetes. However, without more information about the client’s current health status and blood glucose levels, it’s not clear whether a decrease in oral glycemic medication is warranted. It’s important for healthcare providers to monitor and adjust medication dosages based on individual patient needs and responses.
Choice B rationale: Encouraging the client to eat small, frequent meals could be a beneficial strategy. Overeating can lead to weight gain and related health problems. Eating smaller meals more frequently throughout the day can help to control hunger and manage portion sizes, which could potentially help the client to reduce overeating.
Choice C rationale: Instructing the client to weigh themselves daily might not be the best approach. While it’s important for individuals to be aware of their weight as part of overall health management, daily weighing can become a source of stress and anxiety. It might be more helpful to focus on promoting healthy behaviors and coping strategies to manage overeating.
Choice D rationale: Anticipating a potassium supplement for the client might not be necessary. While potassium is an essential nutrient, there’s no indication from the information provided that the client has a potassium deficiency. Overeating does not necessarily lead to nutrient deficiencies, and supplementation should be based on individual needs and medical advice.
Choice E rationale: Teaching the client to plan meals ahead could be a very helpful strategy. Meal planning can help individuals manage portion sizes, ensure a balanced diet, and avoid impulsive eating decisions. This could potentially help the client manage their overeating.
Choice F rationale: Recommending that the client journal about their feelings could be a beneficial strategy. Emotional eating, or eating in response to feelings rather than hunger, is a common issue. Journaling can help individuals identify emotional triggers for overeating and develop healthier coping strategies.
Correct Answer is D
Explanation
Rationale:
Choice A: While social isolation can be a risk factor for suicide, spending time with close friends can actually be protective. This statement alone does not suggest an increased risk.
Choice B: Religious involvement and participation in religious activities can be protective factors against suicide by providing support, meaning, and a sense of belonging. This statement does not indicate a specific risk.
Choice C: Consistent, healthy sleep patterns are generally associated with positive mental health and are not indicative of suicidal ideation. This statement does not raise concerns for suicide risk.
Choice D: Exposure to suicide, particularly within one's social circle or among individuals one admires, is a significant risk factor for suicide due to the phenomenon of "social contagion." The recent suicide of the adolescent's favorite actor increases his vulnerability and necessitates immediate assessment and intervention.
Social contagion refers to the tendency for suicidal behaviors to spread within a community or group, particularly among adolescents and young adults. Exposure to a suicide can trigger suicidal thoughts and feelings in vulnerable individuals, especially if they identify with the deceased or perceive the suicide as a viable coping mechanism.
The adolescent's age (15 years) is also a crucial factor. Adolescence is a period of heightened emotional vulnerability and increased risk for suicidal ideation and behavior due to various developmental and psychosocial challenges.
The father's concern suggests that the adolescent may be exhibiting other concerning behaviors or changes in mood or behavior. The nurse should gather more information and conduct a comprehensive suicide risk assessment to determine the level of risk and implement appropriate interventions.
Additional considerations:
The nurse should inquire about the nature of the adolescent's relationship with the deceased actor, his emotional state since the suicide, and any other potential stressors or vulnerabilities he may be facing.
The nurse should involve the parents in the assessment and intervention process, providing them with education and resources on suicide prevention and support.
If the assessment indicates a high risk of suicide, the nurse should immediately refer the adolescent to a mental health professional or emergency department for further evaluation and treatment.
Remember: Suicide is a serious public health issue, and early identification and intervention are crucial in preventing tragic outcomes. School nurses play a vital role in recognizing warning signs and providing timely support and resources to adolescents at risk.
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