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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. Cloudy dialysate outflow.
Rationale:
A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.
B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.
C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.
D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.
Correct Answer is B
Explanation
Whether the client is a danger to herself or others. When a client is involuntarily admitted to a mental health unit, they are held for an initial period of 72 hours for evaluation and treatment. Afterward, a determination must be made as to whether or not the client is still a danger to themselves or others to keep them in the hospital.
Choices A, C, and D do not address the primary concern of ongoing safety for the client and others.
For choice A, the client's financial status or their ability to pay for prescribed medications is not relevant to their safety or need for hospitalization.
For choice C, the client's ability to make arrangements to stay with someone is important for discharge planning but not for determining their need for ongoing hospitalization.
Finally, for choice D, whether the client is unwilling to accept treatment is important, but not the sole determining factor as to whether they are a danger to themselves or others.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today