A nurse is attending to a client experiencing acute anxiety.
Which of the following actions should the nurse undertake? (Select all that apply.)

Establish rapport with the client.

Avoid making eye contact when addressing the client.

Speak to the client using a high-pitched voice.

Validate the client’s feelings and identify the cause of the anxiety.

Answer and Explanation

Correct Answer : A,D

Choice A rationale:

Establishing rapport with the client is essential when caring for someone experiencing acute anxiety. It creates a foundation of trust and understanding, which can help the client feel more comfortable and willing to engage in therapeutic interventions. Here's a detailed explanation of why rapport is crucial in this context:

Reduces Anxiety: A strong rapport can help to reduce the client's anxiety by fostering a sense of safety and security. When a client feels understood and supported, it can help to calm their nervous system and decrease the intensity of their anxiety symptoms.

Increases Communication: Effective communication is essential for identifying the cause of anxiety and developing appropriate interventions. When a nurse has a good rapport with a client, the client is more likely to be open and honest about their thoughts, feelings, and experiences. This can lead to a more accurate assessment and a more effective treatment plan.

Improves Cooperation: Clients who have a good rapport with their nurse are more likely to cooperate with treatment recommendations. This is because they trust the nurse's expertise and feel confident that the nurse has their best interests in mind.

Enhances Coping: A strong therapeutic relationship can help to improve the client's coping skills. The nurse can provide support, encouragement, and guidance as the client learns to manage their anxiety.

Techniques for establishing rapport:

Active listening: Pay close attention to the client's verbal and nonverbal communication, demonstrating that you are genuinely interested in what they have to say.

Empathy: Show understanding and compassion for the client's experiences and feelings.

Respect: Treat the client with dignity and respect, acknowledging their autonomy and choices.

Genuineness: Be authentic and honest in your interactions with the client.

Trustworthiness: Demonstrate that you are reliable and dependable, and that you will maintain confidentiality.

Cultural sensitivity: Be aware of and respect the client's cultural background and beliefs.

Choice B rationale:

Avoiding eye contact can convey disinterest, disrespect, or dishonesty, which can further heighten anxiety. Maintaining appropriate eye contact demonstrates attentiveness, empathy, and understanding, which can help to build trust and rapport.

Choice C rationale:

Speaking in a high-pitched voice can be perceived as agitated or tense, which can exacerbate the client's anxiety. It's essential to speak in a calm, soothing, and reassuring tone to promote relaxation and a sense of safety.

Choice D rationale:

Validating the client's feelings and identifying the cause of anxiety are crucial steps in effective anxiety management.

Validation helps the client feel understood and accepted, while identifying the cause can guide the development of appropriate interventions to address the underlying triggers.

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Correct Answer is D

Explanation

A rationale:

Incorrect. While patients typically do sleep for a period after ECT, the duration is usually shorter, around 30-60 minutes.

Providing inaccurate information about the length of sleep can lead to confusion and anxiety for the patient.

Evidence: Studies have shown that the average recovery time following ECT is around 30-60 minutes, with most patients feeling alert and oriented within that time frame. (Source: NIH.gov) Choice B rationale:

Incorrect. While ECT can be highly effective in treating depression, it is not considered a cure. It's important to manage expectations and emphasize that ECT is a treatment option that can significantly improve symptoms but may not guarantee a complete cure.

Evidence: Research indicates that ECT has a remission rate of approximately 50-70% in patients with severe depression, meaning that many patients experience a significant reduction or disappearance of symptoms. However, relapse rates can range from 30-50%, indicating that ongoing maintenance treatment is often necessary. (Source: American Psychiatric Association)

Choice C rationale:

Incorrect. Muscle relaxants, not seizure-preventing medications, are administered during ECT to protect the patient from injury during the induced seizure. It's crucial to clarify this distinction to avoid misunderstandings about the procedure's mechanism of action.

Evidence: Standard ECT protocols involve the use of a short-acting muscle relaxant, such as succinylcholine, to prevent muscle contractions during the seizure. This helps to minimize the risk of physical injury and ensure patient safety. (Source: Healthline.com)

Choice D rationale:

Correct. Temporary memory loss is a common side effect of ECT, and it's essential to inform patients about this potential issue to prepare them for the experience and address any concerns they may have.

Evidence: Studies have shown that approximately 40-50% of patients experience some degree of memory impairment following ECT, primarily affecting short-term memory of events occurring around the time of treatment. However, this memory loss is usually temporary and resolves within a few weeks or months for most patients. (Source: Studocu.com)

A. Administer a prescribed anti-anxiety medication, instituting mouth checks to assure it is swallowed. B. Inform the provider about the client’s statement. C. Assure that a staff member stays with the client at all times.

Correct Answer is C

Explanation

Choice A rationale:

Administering an anti-anxiety medication may not be the most appropriate first action. While medication can help to reduce anxiety, it does not address the underlying issue of suicidal ideation. In some cases, medications can even increase the risk of suicide, especially in the first few weeks of treatment.

Instituting mouth checks to assure the medication is swallowed is not a standard practice in this situation. It is more important to focus on ensuring the client's safety and providing emotional support.

Choice B rationale:

Informing the provider about the client's statement is important, but it is not the first action that the nurse should take. The priority is to ensure the client's immediate safety.

The provider can be informed after the client has been stabilized and is no longer at immediate risk of harm.

Choice C rationale:

Assuring that a staff member stays with the client at all times is the most important first step in ensuring the client's safety. This will help to prevent the client from acting on their suicidal thoughts and provide an opportunity for the nurse to assess the client's risk for suicide and intervene as needed.

It also allows the nurse to provide emotional support and reassurance to the client.

Choice D rationale:

Questioning the client about a suicide plan and method is important, but it should not be done until the client's safety has been ensured. Asking about a suicide plan can be triggering for some clients and may increase their risk of suicide.

It is important to approach this topic sensitively and only when the client is feeling safe and supported.

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A nurse is attending to a client experiencing acute anxiety. Which of the following actions should the nurse undertake? (Select all that apply.)

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A nurse is attending to a client experiencing acute anxiety.
Which of the following actions should the nurse undertake? (Select all that apply.)