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","C","E"]
Explanation
Choice A rationale: Potassium level A therapeutic response to the treatment plan for anorexia nervosa would be indicated by a normal potassium level. Anorexia nervosa often leads to electrolyte imbalances, including low potassium levels, due to inadequate food intake and, in some cases, purging behaviors. Therefore, a normal potassium level can indicate that the client is responding well to the treatment plan, as it suggests they are maintaining a more balanced diet and managing their symptoms effectively.
Choice B rationale: Temperature While body temperature can be affected by severe malnutrition, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.
Choice C rationale: ECG report An ECG report can indicate a therapeutic response to the treatment plan for anorexia nervosa. This is because anorexia nervosa can lead to heart problems such as abnormal heart rhythms. Therefore, a normal ECG report can suggest that the client’s heart health is improving, which can be a sign that they are responding well to the treatment plan.
Choice D rationale: BUN level While the BUN (Blood Urea Nitrogen) level can provide information about hydration status and kidney function, it is not a specific indicator of a therapeutic response to the treatment plan for anorexia nervosa. Therefore, while it’s important to monitor, it is not a definitive sign of improvement or recovery.
Choice E rationale: BMI BMI (Body Mass Index) is a key indicator of a therapeutic response to the treatment plan for anorexia nervosa. Anorexia nervosa is characterized by a significantly low body weight, and one of the main goals of treatment is weight restoration. Therefore, an increase in BMI can indicate that the client is gaining weight and responding well to the treatment plan.
Correct Answer is B
Explanation
Choice A rationale:
Avoids addressing the client's behavior: This response does not directly address the client's disrespectful tone of voice. It simply gives the client the schedule and expects them to comply. This could reinforce the client's belief that they can act out without consequences.
Misses an opportunity to set boundaries: Setting boundaries is essential when working with clients with BPD. This response does not establish a clear boundary regarding acceptable communication.
Does not promote therapeutic communication: This response does not encourage the client to share their feelings or explore the reasons behind their outburst. It shuts down communication rather than opening it up.
Choice B rationale:
Directly addresses the inappropriate behavior: This response assertively communicates to the client that their tone of voice is unacceptable. It sets a clear boundary regarding respectful communication.
Models appropriate communication: The nurse models respectful communication by using a calm and assertive tone of voice. This can help the client learn to communicate more effectively.
Promotes self-awareness: This response may prompt the client to reflect on their behavior and the impact it has on others. It can help them develop better self-awareness and emotional regulation skills.
Choice C rationale:
Focuses on the nurse's feelings: This response shifts the focus away from the client's behavior and onto the nurse's feelings. It can make the client feel defensive and less likely to engage in productive communication.
May escalate the situation: Asking "why" s can sometimes put clients on the defensive and lead to further conflict. It's generally more helpful to focus on the present behavior and its impact.
Choice D rationale:
Condescending and challenging: This response comes across as condescending and challenging. It's likely to make the client feel defensive and resentful.
Not therapeutic: This response does not promote a sense of trust or rapport between the nurse and the client. It's unlikely to lead to productive communication or behavior change.
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