A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Allow the client to pace alone until physically tired.

Walk with the client at a gradually slowing pace.

Ask a small group of other clients to walk with the client.

Calmly instruct the client to stop pacing and sit in the dayroom.

Answer and Explanation

The Correct Answer is B

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

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Correct Answer is C

Explanation

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

A. "You should stop because you need to. You are destroying your health." B. "Do you have any idea why you do this?" C. "I'm proud of you for recognizing that this behavior is not normal." D. "It seems like you are feeling helpless about this behavior."

Correct Answer is D

Explanation

A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.

Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.

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A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Correct Answer is C

Explanation

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

Correct Answer is D

Explanation

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