A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone.
The nurse should anticipate planning care for managing which of the following phobias?
Agoraphobia
Xenophobia
Mysophobia
Aerophobia.
The Correct Answer is A
Rationale:
A. Agoraphobia: This choice directly aligns with the client's presentation of being afraid to leave her home alone. Agoraphobia is a specific phobia characterized by an intense fear of situations that the individual perceives as inescapable or that might potentially lead to panic or embarrassment. Common triggers for agoraphobic individuals include crowded spaces, open spaces, public transportation, or being alone outside of the home. The client's inability to leave her home for weeks due to fear is a classic symptom of agoraphobia.
B. Xenophobia: This choice refers to the fear of strangers or foreigners. While the client may experience anxiety in unfamiliar situations, the primary focus of her fear is being outdoors alone rather than encountering unfamiliar people. Additionally, the daughter's description of the client's fear specifically mentions being alone, further supporting agoraphobia as the more likely diagnosis.
C. Mysophobia: This choice refers to an extreme or obsessive fear of germs or contamination. While anxiety related to cleanliness could coexist with agoraphobia, the primary presenting complaint in this case is the fear of being outdoors, not specifically germs or contamination.
D. Aerophobia: This choice refers to the fear of flying or being in high places. There is no indication in the scenario that the client's fear is specifically related to heights or flying, making this choice less likely.
Therefore, based on the specific nature of the client's fear and the limited information provided, agoraphobia is the most probable diagnosis and the one the nurse should anticipate planning care for.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Initiating vomiting and applying an enema is not the first action to take when finding an unconscious person. This could potentially cause more harm, especially if the person is unconscious as they could choke. It’s also important to note that inducing vomiting is not a recommended procedure for drug overdoses as it can lead to aspiration, which can cause more harm.
Choice B rationale: Checking pupil size and reflexes is important in assessing a patient’s neurological status. However, it is not the first action to take. The first action should always be to ensure the patient has a patent airway to allow for adequate oxygenation.
Choice C rationale: Establishing a patent airway is the correct first action when finding an unconscious person. This is because maintaining a patent airway is crucial for oxygenation and ventilation. Without a patent airway, the person could suffer from hypoxia, which could lead to brain damage or death.
Choice D rationale: Administering IV fluids fast is not the first action to take when finding an unconscious person. While IV fluids may be necessary later on in the management of the patient, the first action should always be to ensure the patient has a patent airway.
Correct Answer is D
Explanation
Choice A rationale: Feeling too tired to attend a group meeting does not necessarily indicate anxiety. It could be due to various reasons such as lack of sleep, side effects of medication, or lack of motivation, which are not indications for administering lorazepam.
Choice B rationale: Seeing “purple bugs crawling on the wall” is a hallucination, which is a symptom of schizophrenia, not anxiety. Lorazepam is not typically used as the first-line treatment for hallucinations.
Choice C rationale: Believing that he is a government agent is a delusion, which is a symptom of schizophrenia. Lorazepam is not typically used as the first-line treatment for delusions.
Choice D rationale: “My heart is pounding out of my chest” is a common symptom of anxiety. It indicates that the client might be experiencing physiological symptoms of anxiety such as increased heart rate and palpitations. In this case, administering lorazepam, which is an anxiolytic medication, would be appropriate.
In conclusion, the nurse should consider administering lorazepam when the client states, “My heart is pounding out of my chest.”
Lorazepam is a medication belonging to the benzodiazepine class, commonly used to treat anxiety and insomnia. It works by slowing down the activity in the brain and nervous system, producing a calming effect.
Generalized Anxiety Disorder (GAD) is a chronic mental health condition characterized by excessive worry and anxiety that persists for at least 6 months, interfering with daily life.
Important Considerations:
Lorazepam is a controlled substance due to its potential for abuse and dependence.
It should only be administered under the supervision of a qualified healthcare professional, who can assess the individual's needs and potential risks.
Self-treating with lorazepam is dangerous and can lead to serious consequences.
If you have concerns about anxiety or are considering using lorazepam, please consult a licensed physician or mental health professional for proper diagnosis and treatment guidance.
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